Month: April 2013

Hazard in context: the psychology of medical continuity

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Continuity of care in hospital is a hot topic. It is well recognised that reductions in the hours worked by junior doctors have resulted in a fracturing of the traditional team structure and more frequent handovers between staff as they come off shorter shifts. The Royal College of Physicians published a survey on the subject in February 2012, their press release saying,

‘…over a quarter (28%) of consultant physicians surveyed rate their hospital’s ability to deliver continuity of care as poor or very poor. In addition, over a quarter (27%) believe that their hospital is poor or very poor at delivering stable medical teams for patient care and education.’

Althought improved safety on the wards was a driver for change, a document published by the Royal College of Surgeons, ‘Do reduced doctors’ working hours create better safety for patients? – assessing the evidence’, challenged the assumption that working to the European Working Time Directive (48 rather than 56) led to greater alertness and fewer mistakes. The author Matthew Worral wrote,

‘There is a much greater evidence base to suggest the full-shift system being brought in increases patient harm through greater handovers and stratification of hospital staff. The potential for important information to be missed and inability to access senior expertise at key times are a greater problem for patients.’

Accompanying the move from long on-call periods to shifts has been a reconfiguration of the way patients are assigned to teams. In a soon to be published book ‘The Changing Role of Doctors’ (Radcliffe Health, May 2013), the main strength of the ‘old way’ is neatly described;

‘This firm structure, with the associated working pattern, meant there was a high level of understanding of one another’s strengths, weaknesses, training needs and personality. When this medical team was working at its best, all members of staff felt supported and there was a genuine sense of camaraderie and team spirit.’

and,

Continuity of patient care was of a very high level. Most patients were clerked in by a member of a firm (usually the most junior doctor) and then remained under the same team of doctors for the duration of the stay, regardless of where the available beds were.’

 

This contrasts with the new ‘ward based’ model, where,

‘…the junior doctor and consultant who first admit a patient will usually pass over the responsibility of care for the patient to another team as soon as the patient moves to an inpatient ward.’

 

The ward based model has significant strengths, not the least of which is that patients are directed to teams with expertise in their particular disease, rather than remaining with the ‘random’ team who happened to be on-call on the day they were admitted. Another strength is that work intensity remains constant, rather than fluctuating with the ebb and flow of admissions either side of an on-call day. A major downside is that whenever the patient moves within the hospital (into a side room because of infective diarrheoa, for example), her or she becomes the responsibility of another team. That team will have to review all that has gone before, check the results, get up to speed, and carry on delivering appropriate care seamlessly. The process of developing a full understanding of the patient’s needs and goals must be repeated. Rapport must be rebuilt. Subtleties may be lost. Errors can be made.

What is at the heart of these errors? System failures, ‘dropped batons’, poor communication…all are likely contributors. Professor Roy Pounder, contemplating the effects of reduced working hours, highlighted these factors in advance of the EWTD changes:

“Seeing a patient once or twice before handing over to the next doctor, who then does the same after a short period, means it is difficult to detect a subtle deterioration in a patient’s condition.”

But I wonder if there is a deeper issue, related to the way doctors understand their patients. The psychology of discontinuity. This needs to be adressed from the point of view of both patients and doctors.

Patient experience: anchorage

A 2002 BMJ paper, ‘Continuity of hospital care: beyond the question of personal contact’ offered some good insights into patient experience, using the following quotes;

“They keep asking the same questions…”

“My file was not present and new doctors were not informed of my situation”

“You always get different orders from new doctors”

“Too many doctors! A second opinion is OK, but the sixth and seventh are quite frustrating…”

These are the more obvious symptoms of discontinuity, but they do not describe fully the sense of vulnerability and frustration that I have sometimes detected. When I see a patient in the emergency department or acute admissions ward, a common question is,

“Are you going to be my doctor now?”

or,

“Will you be coming back to see me again? Will I see you tomorrow?”

I interpret such questions as an appeal for permanence or anchorage in the huge, complex system into which they have been delivered. Patients, it seems to me, are desperate to make a connection that can be relied on. If I know that the patient will come to my ward, I can answer ‘Yes, I’ll be along to see you tomorrow…’ and there may be a visible relaxation in their anxious expression. But if not, I have no choice but to explain, ‘No, it won’t be me who sees you from now on…but one of the other teams, lung specialists…’ Sometimes, if I have spent a good deal of time speaking with them, digging down in important medical or social details, I will add, ’But we will make sure they know all about you…about everything we have discussed…’ If it is a crucial fact I will make a point of telling the new team, but more often than not such hand-over of information will occur on paper, in the notes. This requires a clear handwritten entry, a transparent narrative. It is not uncommon for me to see what has been written by the junior doctor accompanying me only to realise that they have not interpreted the patient’s words in the same way I have. The emphasis is not quite right. So I re-write it, and leave the ward hoping and expecting that whoever receives that patient will see my note and make sense of it. This is an attempt to maintain the chain of continuity.

I wonder if the psychological distress that derives from uncertainty, not knowing if someone in the machine ‘owns’ you, if someone is personally invested in your wellbeing, may be sufficient to undo the benefit of technically correct, well timed medical interventions.

Fast track empathy

How do lack of continuity and the diminished feeling of ownership that follows, influence doctors in a way that jeopardises safety? It may hinge on empathy.

Serious illness requires the application of powerful medical interventions. These bring with them the potential for hazard. Recent debate about ‘zero harm’ culture has crystallised the notion that medicine and its tools can do as much harm as good. To avoid harm staff must be vigilant; they need to keep an eye on the details, spot irregularities, check the blood tests, double check the drug charts, maintain the ‘housekeeping’ (as it is sometimes called), and anticipate complications. These duties should be automatic, but they are done better if the doctor knows the full story. If they have gained a full appreciation of the patient and their background they will understand better the true impact of those potential harms. Risks and harms can appear abstract, but when they are imagined in the context of the whole person they become tangible, transforming from theoretical ‘adverse events’ to personal tragedies. A better understanding of those risks may motivate doctors to work harder in ensuring that each job is done properly. Otherwise they will not be letting down, ‘…the lady in bed 25, acute kidney injury…’, but ‘Mrs Jones…she was hoping to get out in time to attend her grand-daughter’s wedding this weekend…’ Continuity encourages personalisation, personalisation permits the exercise of empathy, and empathy gives our actions relevance.

The challenge for doctors working to shift patterns and caring for patients who arrive to their ward areas on a daily basis, is to learn the practise of empathy in compressed timeframes. This requires active listening, generous emotional investment…energy. But to ensure that connections between patients and doctors are made within the restrictions of the modern hospital environment this has to happen. Otherwise patients will flow through wards without knowing if anyone really ‘owned’ them, or who that person was. And doctors will float from patient to patient without understanding quite how much trust was being put in them.

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The day assisted dying became legal: choices

As a supporter of assisted dying (AD) I ask myself  – ‘What will I actually do if it becomes legal?’ I haven’t travelled to Oregon or Washington state to see how it works, nor have I talked to doctors or nurses who are involved, but I think it is important to anticipate one’s response. After all, a recent NEJM paper described in a routine, academic, matter of fact way, how a ‘Death with dignity’ programme was rolled out in a Seattle cancer centre. If AD is legalised in the UK, any doctor who works in the field of cancer or palliative care will be touched by it in some way. The degree of involvement will depend on some of the thought process that I explore in this post.

For those who oppose AD it will be relatively simple – if a patient asks about AD you will make it clear that you do not ‘do that’. But it will be necessary to refer the patient on to a colleague who does. To refuse would be to obstruct the patient’s access to a legal therapeutic option. There are parallels with abortion here.

What about those who are ambivalent? This is probably the majority. When the day comes, will it be necessary to make a choice, to be an ADer or non-ADer? Will it be necessary to register that preference, for the sake of transparency? Perhaps it will be possible to avoid making that choice for a few months, a year…until a patient asks you to help them. If you are not completely ‘anti-’ but you have no wish to be involved in assessing them and certifying the terminal nature of their illness, you will again have to refer on. Over time you may be persuaded by the conviction of your patients, and begin to recognise that by referring on and leaving such distasteful tasks to others you are separating yourself from the patient’s journey too forcefully. You might conclude that it is cowardly, in a way, to ‘wash your hands’ of them when the going gets tough and they ask for your signature on the piece of paper, the document, the booklet…whatever it is. You may review your position, and change, finally accepting that ‘Yes, quite a few patients have asked me now, AD is a fact of life, why should I make their progress any more difficult than it is already?’ Others will remain intellectually neutral, but for good reasons they will continue to maintain clear blue water between their own practice and AD. That will be perfectly understandable. I can foresee many doctors adopting this approach.

And what about doctors like me who instinctively support AD? This is where I get nervous. If, a month after the law is passed, a patient whom I have recently diagnosed with terminal cancer (a common enough event) sits down in my clinic and says, ‘When the time comes I want an assisted death. How do I arrange it?’ – I will have to do everything in my power to facilitate it. To do otherwise would be hypocritical. So, I might have to decide that I am happy to be one of the signatories, but not so happy to prescribe the fatal dose. Or I might decide to push myself through that discomfort barrier, propelled by a self-imposed reluctance to abdicate my professional responsibility to care for the patient, and volunteer to be physically involved in the prescription and administration of the fatal dose. If I do that I must prepare myself for the experience of being with someone who is not imminently dying, who is still independent, in the last hour of their life. I will have to remain strong and unflustered (the last thing they will want to see is a nervous clinician) as they arrive, confirm their identity, take to a bed, gather their family around them, reach for the ‘milky drink’, and expire. Am I ready for that? Are you?

“It was as though I wasn’t there”: the problem of the invisible patient

The CQC has published the results of its 2012 national in-patient survey. Some aspects of it were picked up by the Independent newspaper on 16th April 2013. One of the observations in the ‘Doctors and Nurses’ section is that:

There have been improvements in the results for questions asking about doctors and nurses, with the majority of respondents saying that:

Doctors (75%, up from 73% in 2011) and nurses (81%, up from 78% in 2011) did not talk in front of them as if they were not there.

 

What is the explanation for the other 25% who feel that their doctors did talk as though the patient wasn’t there?  

1) The doctors thought the patient was not listening, or not able to comprehend what was being said…but they were wrong.

The only way to avoid this would be never to speak to a third party (usually a colleague, often a relative) over a patient, even if they appear unconscious or severely impaired cognitively. That seems a sensible rule of thumb…but go to any intensive care unit and you will see very open discussions, concerning life and death, just feet away from sedated patients. It happens. Clearly, as medical practitioners, we are prone to falling into the trap of underestimating the degree of cognitive function in patients who appear, externally, to be unengaged with their surroundings.

 

2) The doctors conducted technical, impenetrable discussions with colleagues without taking in account the patient’s bewilderment.

Here I would like to mount a defence of doctors. On a ward round there are several tasks that have to be achieved. Most, but not all, can easily be followed by a non-medically trained person.

  • Greeting and introductions
  • Ascertainment of the patient’s current symptoms, feelings and concerns,
  • Confirmation of what has occurred thus far during the admission
  • Physical examination if appropriate
  • *Review and scrutiny of medical investigation
  • *Interpretation of above data
  • Agreed plan (in context of patient’s goals)
  • Communication of that plan to the patient

 

  • *Additionally, there may be opportunities for teaching.

 

The starred (*) elements may, in my view, evade the patient’s full understanding. This is because the language used will contain technical terms, Latin or Greek derived terminology and a cascade of acronyms. I experienced an example of this recently – there was patient with ‘the best bronchial breathing you’ll ever hear’. I explained to the patient that he had signs of pneumonia, asked him if the FY1 (the most junior doctor) could listen with her stethoscope, and had the following discussion with her and the team:

            ‘What did you hear?’

            ‘Loud breath sounds.’

            ‘How did it compare to the other side?’

            ‘Louder.’

            ‘Just louder?’

            ‘Different.’

            ‘I would say clearer.’

            ‘Yes, it was.’

            ‘And do you know why?’

            ‘The lung is solid…’

            ‘And that’s called….?’

            ‘Bronchial breathing’

            ‘Yes! Well done. And then you might look for other signs such as increased vocal resonance, vocal fremitus, signs that the sound waves are being transmitted through solid lung rather than open alveoli…you might see air bronchograms on the chest x-ray…Mike, what was the white cell count and CRP?”

            “12.8 and 87.”

            “Strep antigen, has that been sent…”

            “No. But he’s on Co-Amox and Clary…”

 

And it’s moved completely out of the patient’s sphere of understanding. I look down, aware that we have progressed onto discussing his laboratory results, and treatment…the mini-teaching session has segued into person-specific details, and the patient does not have a clue what we are talking about. If he was asked to comment on a survey he might well say, ‘They talked as though I wasn’t there!’

 

How do we avoid this? Vigilance. Being aware that every single word uttered will be heard and reflected upon by the patient. Any unguarded word. Comparisons with other, historical patients (‘…you remember the man we saw last week, on intensive care, he had the same signs…) may lead the patient to fear that they will follow the same course. Mentioning a theoretical differential diagnosis (‘…this could be tuberculosis, or a tumour can cause compression and distal collapse…’) will cause them to dwell on all the terrible possibilities. It’s just not possible to talk ‘freely’, even though there may be a purely medical justification in considering other diseases or treatments.

 

Two solutions to improving our conduct during those starred sections are:

            a) always use non-technical language

            b) move away from the patient’s bedside.

 

There are problems with both in my view.

 

a) efforts to avoid technical terms during conversations with colleagues often result in a pseudo-medical, strained and patronising tone, or in asides that contain semi-interpretations . For instance, ‘…we mean the lung has gone solid, from the pus in the air-sacs…it’s a normal finding, in pneumonia…fremitus, that means the sound vibrations are felt on the skin…’. Many patients would actually appreciate such interpretation, as it provides an insight into their own condition. Within reason I would support it, but, to be honest, it is the student or house office we are trying to teach about physical signs, not the patient. Certainly in communicating the interpretation and plan such non-technical terms must be used, but in their right place I think the ‘code’ that doctors use is necessary.

 

b) moving away can be cumbersome. It may also give the wrong impression, that something more grave is being discussed in secret. Afterwards, the team must go back to the bedside, so an additional awkward phase, wherein the team trundles off to the corridor or nurses’ station and then trundles back is introduced. To do that with each patient on a 30 patient ward round is probably unfeasible.

 

We must find a way of making the patient feel involved while having a discussion that they cannot truly be involved in. This is a demanding expectation. Clearly, in 75% of cases, we achieve it. Perhaps it is in those cases where alert and interested patients with complex and subtle problems that seem to require prolonged technical discussion make up the other 25%. In these cases the acronyms and the secret codes go on and on, interspersed with concerned glances back to the increasingly concerned patient in his or her physically inferior position on the bed…followed by a brief, concluding summary that reminds the patient of one of those comedy sketches where a dishonest interpreter transforms a 90 second string of Chinese into a two word English phrase. It’s all about sensitivity and empathy in the end.

 

My take home message would be – Yes, sometimes it is necessary to talk in a way that will not be fully understood, but make sure the patient is forewarned about those portions of the visit, and make sure you check that their degree of comprehension has been addressed with a suitably clear interpretation. And don’t leave without checking that their questions and concerns have been dealt with.

Memory failure after medical error: the building blocks of experience

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There is a contradiction in medicine that has always interested me – the need to form a complete psycho-social picture of each individual patient (aiding empathy) versus the need to depersonalise, categorise and store their medical story (thus adding to experience). When things go wrong, this tension results in a paradoxical lack of humanity.

Example: a junior doctor, two years qualified, makes a mistake. She writes the wrong antibiotic up on a Friday afternoon, having failed to check the result of cultures that were taken three days before. The bacteria causing the infection is not sensitive to the antibiotic that she prescribes. The patient deteriorates. The doctor recognises and regrets her error, watches the patient and his family, learns all that there is to know about his life and background. He dies two weeks later (his death the result of mutiple diseases, not just her action). She is devastated. For days and weeks she reflects on her mistake. A vivid image of the family keeps entering her mind, as do their words, when they asked how a simple urine infection could make someone this ill. Moreover she checks the computer assiduously before prescribing antibotics from then on.

Twelve years later she is asked to deliver an induction lecture to new doctors. She emphasises how important it is that they check each result for themselves, take nothing for granted…watch the details. She is a very careful doctor, always was really, except for that one slip which happened early on. She drives home…and casts her mind back to the moment she learned that her patient had grown worse over the weekend, due, in part, to her brief incompetence. She finds that she cannot remember his name. She cannot form a picture of his face in her mind’s eye. The family…how many were there? The man has gone…only the error, and the lesson that grew out that error, remains. The individual has been subsumed by history, by a thousand other patients with a thousand different problems.

We cannot be expected to remember every patient, of course. But those who made the greatest impressions on us might, you would think, linger on in our memories. Indeed they do, but mainly in the form of salient facts – the features and factors that made them special, be they medical, situational, or personal. Their memory survives as a construct that exists only in relation to the effect it had on you, the doctor, rather than the self-contained, individual and tragic story that the patient’s demise truly signified in their world…a world that you, as their doctor, were never really a party to.

It is a subtle and rather esoteric observation, I admit it, but for me it feeds into a larger question. How do doctors ‘process’ the memories of patients who once presented a great medical or personal challenge?

A mature doctor will have been buffeted and battered by numerous ‘bad outcomes’. That cold phrase describes unexpected injury, suffering or death of patients related to decisions or treatments ministered by us, their doctors. Those outcomes may have been inevitable, but the fact that they occured after we saw them and gave advice forms a link in our mind. Was it something I did? Should I have made a different decision? Was I wrong? And if I was wrong, what will I do differently next time? A lesson is learnt, and each little shock, each piece of bad news, adds to the pattern of experience that forms the value of a good doctor. We carry those lessons around with us, making sure that next time we encounter a similar situation we do not make the same mistake. We get better, and feel more confident. The price – a series of personal tragedies that become smaller and smaller in our memory as time passes. All but the most harrowing (or perhaps those that resulted in sharp criticism or proessional censure) lose their emotional edge. We recall the events in abstract – ‘I did this, this happened, he died, I felt awful…oh yes, I don’t recommend it, don’t ever do that…’ – but we are no longer visibly damaged. In fact we are wiser and stronger, and at some level perhaps we are grateful for having been through it.

My point is that the lifelong process of learning that is a medical career requires us to find a way to live through these setbacks and make something positive out of them. To do this doctors must strip those memories of the very qualities that made them so powerful in the first place…the patients’ suffering and the impact this had on those around them. The lesson learnt is usually one of process, data interpretation, practical technique or communication…whatever it is it is something to do with the doctor. It is the doctor who is the constant, whereas the patient, even though their specific needs and problems formed the basis of the risk, is one of many who will cross that doctor’s path.

So is all this a problem? It is if we become too good at the process of assimilation and are tempted to put each mistake ‘down to experience’ too soon. It is if we do not dwell sufficiently on the impact of mistakes that, from a medical point of view, were purely ‘technical’. It is if we immediately compartmentalise those errors, surrounding (or hiding) them in hastily erected walls of rationalisation, forensic examination and (instinctive) defensiveness, thereby underplaying their social significance. I wonder if such post-hoc failures of imagination and empathy that can lead to a lack of candour. When errors are immediately assessed in relation to the system that caused them rather than the social unit, the family, that was most directly affected by them, we are in effect turning away from the pain and settling our gaze on our own concerns. That has to happen of course, if weaknesses in the system are to be adressed, but the timing and the emphasis have to be right.

Personally, as a doctor who has been blown off course as frequently as any other, I think depersonalisation and abstraction are vital. They are not particularly warm or human traits, but they are understandable. The process of learning from experience must be the same for doctors as it is for any other professional, and the same need to filter, discard and retain the ‘essence’ of each incident applies. The difference, for doctors, is that the extraneous matter is often deep emotion and human pain.

NHS2 in the year 2053 – a sideways look at the future

The Hub headquarters, glass clad and monolithic, glistened from its dominant position at the north end of the campus. I stared up at it, but was soon drawn back to the shabby, warehouse-like building to my right which appeared to have received little attention since the winter of ’45, the year I had worked in it as an intensive care doctor. We called it the ‘Lung’ back then.

A new influenza strain had swept through the country, the largest epidemic since 1918/19, and most of those infected developed respiratory failure. Because there was a national shortage of ventilators we relied on five powerful, central bellows A to pump oxygen via filtered tubes into fifty intubated patients at a time. It was hell. Two trainee doctors and eight nurses looked after each fifty patient cohort. It was one of the reasons I packed it all in. Each morning as I walked in, and each night as I walked back to the magnatram terminal, I saw the lighted windows of the other unit, where patients slept, artificially, to the sound of their own machine.

Six months later I gave up medicine to become a social historian. And that’s why I had returned, to the North Eastern Health Hub – to conduct research for my new book. The Hub had grown while its competitors in the region had closed down…or, more accurately, had been absorbed. The medical staff moved across, local managers evaporated, the bricks and mortar were flattened. The magnatram was jammed with patients arriving for their appointments. The Hub was massive now – a hospital town.

As the lift approached the executive floor I began to get nervous. Professor Sam Laszlo, or his PA, had put aside forty-five minutes. In that time I had to discover all I could about how his company had come to dominate the UK health market. I knew he would be coy about some things…but I hoped that pride would feed his honesty.

He smiled openly, his tall silhouette framed and blurred in window of bright blue sky behind him.

“Hello! Thank you for coming today. I’m sorry we don’t have much time…”

“Any insights would be gratefully received…it’s a bit of a coup to get to meet you.”

“ I understand you worked here once.”

“Yes. Intensive care. In the Lung.”

“The Lung?”

“Down there.” I pointed over his shoulder, for the roof was visible below us.

“Ah. Of course. I apologise. It’s got a quite different use now.”

“It looks pretty neglected to me.”

“Not on the inside. Not at all. It houses the fibreoptic data spine, and the refrigeration units to keep the hardware cool. Since the UniRecB scandal we have had to keep all patient data on-site. A pain, but there you go. Anyway, tell me, remind me, what is title of your book? You sent it to me but I don’t have it with me.”

“‘Two Tears: The Long Dying of NHS1’. But I might change it. That’s ‘tears’ with an E and an A.”

“Two Tears! Ingenious! But why not ‘In Pursuit Of Excellence: How NHS2 Put The Patient Back In Charge?”

“I err…come from a rather socialist background. I’m cynical about the changes…”

“But it was New Labour who let us in. You won’t remember personally of course, but after Cameron won a large majority for the Old Conservatives in ’15, on a welfare-immigration ticket, ably assisted by the nascent economic recovery, New Labour begged David Miliband to come back from the States. He shook them up, rode the economic recovery and promised a happier life free of austerity…and they won in 2020. Small majority mind you. The new health secretary, Burnham, was held by a few to the promise he had made in 2012 to repeal the Health and Social Care Act, but it was too late [1]. The benefits had become clear. It was the quality you see. New Labour didn’t even have to discuss health in their manifesto, there was no hunger for change anymore. People were happy.”

“The healthy majority were happy.”

“No, patients were happy. Qualified Providers came in, staffed their establishments properly, asked their patients about the experience, changed what they didn’t like, dealt with complaints promptly, sacked doctors and nurses in the lowest 5% on their real-time bedside compassion scores…how could Burnham dismantle it? Private companies were soon providing 25% of secondary care, it was growing at several percentage points per year. Trusts all over the country had budgeted for huge increases in income from privately ensured patients [2]. It was done.”

“But by that time there was evidence of inaccessibility…”

No-one was excluded. Remember, the state was still funding healthcare – and increasing it –  as it does now, no-one had to pay anything to get treatment…”

“Isn’t that disingenuous? State funding fell in proportion to national health needs estimates, provision became second class. This was described in the Scott review in 2024. There were already identifiable, statistically significant survival differences between NHS and privately insured patients…”

“In a few conditions only.”

“Cancer…”

“But cancer is no longer an issue, not in the era of vectorgen therapy. By 2022 that technology was already coming through. Successive governments saw that and planned strategically to account for a reduction in demand. A poor example…for your book. Don’t hang your thesis on cancer. The story isn’t in mortality, it’s in quality of life. Private companies were soon demonstrating a greater focus of quality of life…”

“…because those companies concentrated on the non life-threatening conditions. The routine, relatively safe stuff…non-urgent surgery for healthy people. That’s how you get great Patient Reported Outcome Measures.”

“How can you say that? What are we most famous for?”

“Hegemony.”

“We are dominant now, I agree. But clinically?”

“The HEPMatrix, I guess.”

“Yes! We poured resources into a group of patients with high mortality, very little hope, that no-one had tried to help before, and we changed the game. What happens now when alcoholics or Hepatitis QC patients decompensate? They are plugged into the HEPMatrix until they recover. It’s revolutionised the care of liver failure. My predecessor in this office was awarded the Nobel prize. I won’t accept this overwhelming negativity. We do benefit society…we make money yes, but we re-invest…”

“You have to re-invest, to create new markets. The HEPMatrix did that. It opened up a massive market, and the state had no choice but to pay you to provide the machines.”

“The HEPMatrix would never have come about without private investment. You must understand that. We ran research programmes from the outset. It’s altruistic, clearly.”

“Are drug companies truly altruistic? No. It’s their business. Health is your business. You wouldn’t invest in research unless, on balance, you made money out of it.”

“The two are intertwined. Healthcare has never come for free, somebody pays. Just as we pay for food, water, energy, CO2 removal…you grew up regarding clean air and a stable climate as basic human rights, but twenty-five years ago, when you were what – three or four years old? – we were all taxed for those electrolised graphene spongestacks you see on the horizon. Every industrialised country in the world did the same after the Mumbai Olympics were washed out and the European drought of 2026/27. Health does not come for free. Someone must make money out of it, but as long as that money is made ethically, and used well, what’s the problem? My shareholders are not evil men and women. They work. They too will get sick someday.”

“And none of them will go state.”

“It’s so lacking in objectivity, your line of questioning…”

“I have a responsibility to dig. In the time we have I’ve got to stress my sources a little bit…do you mind? I want to know about the separation. What precipitated the overt separation of state and private funded health streams? It’s not something you find written about much.”

“It’s convoluted. When the double-prion phenomenon began to reveal itself in the huge wave of pre-senile dementia, it became clear that disease progression could be halted if the diagnosis could be made within six months of disease onset and a course of three, 72 hour extra-corporeal cerebrospinal fluid fractionations. General practitioners were urged to screen their patients, and this led to a massive increase in referrals to neurology clinics around the country…”

“ …and the true two-speed nature of New Health Streaming (NHS2) was revealed.”

“Quite. It had been going on for years of course, that’s what the Streaming structure was all about…but the double-prion epidemic, Marshall’s diseaseD, showed up its…vulnerabilities.”

“You mean only those who were insured got seen and treated in time.”

“Only a condition with such a short window of therapeutic opportunity could have done it.”

“How thoughtless of it.”

“It could not have been planned for.”

“But it happened. New diseases occur all the time. Whatever system we have needs to be able to handle them, equitably.”

“NHS2 was doing just that, both streams were audited and proven to work within clinically acceptable timescales. Until then there were no real inequalities…”

“…until the McCartney report smashed that illusion. She showed, five years later, that among the uninsured permanent dementia was eight times as prevalent than among the insured. Because they didn’t get seen in time. Two streams…”

“New Health Streaming was developed democratically, in the oldest parliament in the world. The populace agreed, in principle, that those in work, and therefore insured, should be seen sooner, as their health was more important to the community. You think that’s evil…the voting public did not. How else do you think the Cameron government, the government that facilitated and welcomed the arrival of Any Qualified Providers, how else do you think they got voted in again in 2015? They had a mandate by then, and New Labour did not reverse it.”

“I don’t believe the populace always reach the right decision.”

“Ahh! So perhaps a Communist regime, ruled by wise oligarchs who know what is best for their people, would suit you better! That went well in the mid 20th!”

It was going a bit wrong by now. I glanced at my watch and saw that time was running out. The professor looked down at the glass surface of his desk. I watched his eye track a new message, but I could not read the words from where I sat.

“How interesting!” he exclaimed, looking up sharply, “I know more about than you realise. You do have an agenda after all. Care to tell me about it, or shall I tell you what I know?”

“What do you know?”

“Your mother succumbed to complications following the removal of her colon…an operation she asked to have after receiving the result of a LifeSpan assessment. You’ve been politically active since your late teens. Demonstrations, i-pamphlets…and then you worked here. In the ‘Lung’. If I had known all that I wouldn’t have…”

“Seen me?”

“I don’t know. How old were you when she died?”

“Seven.”

“That was what, early 30’s, we had just published the PicassoE paper. A little earlier and perhaps she wouldn’t have given Lifespan as much credence.”

“Well she did. It gave her an 89% lifetime bowel cancer risk, with a high chance it would be biologically aggressive and unamenable to early detection, curative surgery or vectorgen therapy. It’s understandable, what she did.”

“Our analysis of Picasso’s DNA gave him a 79% chance of a similar disease. And he lived to a good age. Tragic.”

“But your company owned LifeSpan.”

“We sold it after the first cohort of adverse prophylactic procedures.”

“Five years later. After thousands of unnecessary procedures.”

“Not all were unnecessary. Many people were saved. That’s a fact. Once again, your Manichean view is proved to be naïve. It’s all about balance. Society, which includes this company, wavers across the correct path, to the left and to the right, as it develops new technologies and discovers how to apply them, but the correct path can only be charted in retrospect. Don’t blame the innovators.”

Click

The tape recorder in my jacket pocket had run out.

“Tape! How quaint. Of course, your G-glasses would have been taken off you downstairs. The screener would never detect a tape recorder. But you should have just asked, the audio file would have been in your cloud before you opened the door to leave. It still can be. I’m not embarrassed.”

“Is that it then?”

“I think so. Don’t you? I hope it been useful.”

Notes

A – The bellows were steeped in irony. The Hub had brought them in a few years before the influenza epidemic  hit to manage the Guillaine-Barre outbreak of ‘42, itself caused by a faulty influenza vaccine. The chief executive in charge of the manufacturing company who signed off the use of cheap porcine substrates (leading to xenomyelinic cross-talk) is still in punitive re-profiling on the North Sea hulk-network.

B – The ill-fated attempt to provide a unified system with which to access the medical records of all patients, nationwide, had a promising start. UniRec rolled out in 2024 and received positive reviews from primary and secondary care. Patients too were able to access their medical details from home and on their smart devices. However the financial regulator, while investigating the stellar performance of a private insurance provider, Longevity+, in the financial year 2027/8 discovered that the confidential medical details of over 80% of their applicants had been accessed. All those rejected for insurance cover had early indicators, in their bio-informatics, of chronic disease susceptibility. After this scandal UniRec was dismantled and all physical and wireless connections between regional databanks were severed or firewalled.

C- Hepatitis Q was discovered in 2038. It was identified, retrospectively, in archived biological material as far back as 1987. Although blood borne, the virus did not appear to have been passed to blood transfusion recipients, probably due to its exquisite sensitivity to citrate, an additive used in packed red cell storage. In any case, since 2032 red cells have not been used for transfusion, the advent of Self-Terminating Oxygen Delivery Nanobots (STODNs) having made this practise obsolete. The Hep Q epidemic of the late 30’s and early 40’s was caused by a single infected narcotics developer who isolated and then mass produced a novel hallucinogen from his own bile.

D – The currently accepted explanation is that a new, equine prion (proper nomenclature PrPeq/valupak/2012) was acquired through contamination of processed meat and ready-made meals in 2012/3 (and probably for several years prior to this). This interacted with the highly prevalent but latent ‘new variant Creutzfeldt-Jakob’ (nvCJD) prion. nvCJD was related to Bovine Spongiform Encephalopathy (BSE) which entered the human food chain in the final decade of the 20th century. Cows, natural herbivores, had been fed meat and bone meal derived from  sheep infected with Scrapie, and calves which received protein supplements to accelerate growth.

E – Picasso’s DNA was extracted from a bone fragment, retrieved with the permission of his estate from his grave in Vauvenargues, Eurorealm Subzone 26 (formerly Provence-Alpes-Côte d’Azur, France). LifeSpan were criticised not only for driving people to unnecessary surgery on healthy organs, but for a number of suicides (2,347, proven association) that occurred in the weeks prior to a ‘likely date of death (natural causes only)’ that was provided, at extra charge and without guarantee, to their clients.

References

[1] Speech to Royal College of Midwives’s annual conference in Brighton, 16th November 2011

http://www.guardian.co.uk/society/2011/nov/17/labour-repeal-nhs-bill

[2] Freedom of Information requests in 2013 revealed that Trust (NHS1 terminology) planned to increase income from private patients by up to 200% or more in the first years following the Health and Social Care Act/Any Qualified Provider agreement.

http://www.guardian.co.uk/society/2013/apr/06/nhs-hospitals-increase-private-patients

Apologies and acknowledgments: Isaac Asimov, Philip K Dick, David Mitchell, Arthur C Clarke, and all serious health commentators out there.

A ‘Never Event’ and the chain of the blame

This is an example of worst case scenario thinking. It is an entirely fictional case. I have used the same approach that I use in my medical fiction, working out how, within the boundaries of plausibility afforded by standard clinical processes and environments, a particular error might occur. Perhaps this accident happened somewhere, sometime…I don’t know.

This exercise in imagination is intended to show how difficult it is determine where blame lies. Few medical mistakes, in my experience, occur because one person made one mistake. There is often a ‘series of unfortunate events’, each one of which could, perhaps should, have been recognised and reversed before the next occurred. As I read about the ‘duty of candour’ in the Francis report on Mid-Staffs, and read about Jeremy Hunt’s response to it on behalf of the government, I reflected that each time a patient is harmed it will become necessary for hospital Trusts to make a judgement as to whether the incident requires a patient or family to be contacted (whether or not they have complained). It is clear now that there will be no legal compunction for individual healthcare professionals to admit to and communicate these errors, but organisations as a whole (embodied by ‘the board’) will have to recognise and act on that duty. It is not clear to me how this will work. Organisations are collections of individuals, and for the truth about avoidable harms to rise to the top those involved on the shop floor will have to be honest and forthcoming.

I wondered how individuals would respond in a ‘harm’ situation. I tried to imagined a scenario that should never happen, but did. Never Events are medical mistakes that the NHS Litigation Authority (NHSLA) have deemed avoidable and, to be blunt, indefensible. They are, ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.’ Never Events are reported annualy, and spikes in their frequency tend to be picked up by the press (as in Derriford, Plymouth in March 2013).

One Never Event is when liquid food is poured down a nasogastric feeding tube (NGT) that has been accidentally inserted into a lung. If food is dripped into such a misplaced tube the patient will literally begin to drown, and the consequences of this range from becoming transiently short of oxygen, to developing pneumonia, requiring mechanical ventilation or dying. Hospitals have protocols that are designed to ensure that this never happens, and the NHSLA has published algorithms to minimise the risk.

Here then is a reconstruction of how this Never Event might happen; as you read it, ask yourself who is to blame and how it might be communicated to the family.

 -/-

The date was 2rd February 2013 (a Saturday).

Mr Mohammad Ghazi was 78 years old, and had been admitted one week previously with a stroke which affected his ability to swallow. He was fed via a NGT, but on two previous occasions he had accidentally dislodged the tube.

Dr Martin Simpson didn’t know Mr Ghazi. He was asked to get involved at 5.30pm on the Saturday in question. The nurse in charge of the ward, Susan, called him to report that Mr Ghazi had pulled out his latest NG tube in the morning, and that she had inserted another at 3pm. However she could not get a reliable pH (gastric acidity) reading from the aspirate, which she attributed to him having residual feed in the stomach and the fact he was on high dose acid supressants. Without the acidity test she could not confirm that the tube was actually in the stomach, ans protocol dictated that a chest x-xray (CXR) was required. Martin agreed to arrange the CXR and promised to look at it before he finished his shift at 9pm. He asked Susan to bleep him when the x-ray had been done; he was going to be busy clerking new patients in A&E, as the registrar had requested that he help the admitting team during the traditional early evening rush. Martin sent an electronic x-ray request through and forgot about it. Someone would let him know when the x-ray was ready.

At 8.30 pm Susan walked onto the ward having popped out to pick up a drug from pharmacy for another patient. She held the door open for the porter who was bringing Mr Ghazi back from the x-ray department. She helped the porter wheel Mr Ghazi’s bed into the empty bay and, noting the time, went to bleep Martin. He answered promptly, logged on to the x-ray programme on a computer in A&E, scanned along the list of Mr Ghazi’s x-rays, clicked onto the one dated 3/2/2013 and saw that the tube position was perfect. The tip of the tube lay well below the diaphragm, it crossed the edge of the main airway, it was definitely in the stomach. He called the ward, Susan answered, and Martin confirmed that he was happy for her to commence the feed that night. Martin left at 9.30pm. Susan left at 10pm, leaving it to the next shift to turn the feed on.

At 11pm the ward sister on the night shift, Mary, answered the phone. It was the x-ray department, ringing to see if Mr Ghazi was available to come for his x-ray. Mary answered that he had already had it. No, said the radiographer, the request hadn’t been checked off. ‘Why was in he taken down to the department earlier then?’ asked Mary. The radiographer checked the system – oh yes, that had been for an ultrasound which had been booked a couple of days ago; the on-call radiologist had decided to do it that evening in order to clear the backlog. He hadn’t yet had the x-ray for the new NG tube.

Mary ran to the bedside. Liquid food was being dripped into the tube. Mr Ghazi was breathing badly. She stopped the feed immediately and called the medical team. The night doctor came to the ward and logged onto the x-ray programme. The x-ray that Martin had looked at was the wrong one – the right date, but the wrong time, taken in the very early hours of the same day to check the previous NG tube, the one that had been removed.

Mr Ghazi developed pneumonia, deteriorated and died a week later.

Investigation – assumptions and facts

The investigation showed that Martin had indeed looked at the wrong x-ray, and that the right x-ray had never been done. Susan was mistaken in telling Martin that the x-ray had been done – when she saw Mr Ghazi returning to the ward with the porter she had assumed, erroneously, that he had just had his x-ray. That assumption went unchallenged, and when Martin saw that an x-ray had been performed on the relevent date he assumed this was the new one. He did not check the time.

When the x-ray was eventually performed it showed that the new NG tube was in the right lung, and the lung was already turning white, filling with liquid feed.

Testimonies

Susan: I saw him being wheeled in. It was natural to assume he was coming back from his chest x-ray. I didn’t even know he was booked for an ultrasound. He had come to our ward the day before, it must have been booked when he was on the other ward. The timing fitted. Do I think what happened is my fault? No, actually. It wasn’t me who checked the x-ray…

Martin: I’d never met him. I didn’t know him, didn’t know he’d had an NG tube down just the day before, that it had been x-rayed overnight, at 2 in the morning! Susan…and I’m not blaming her…told me that he had come back from his x-ray. I saw on the computer that there was an x-ray taken on the day in question, it looked fine. Why didn’t I check the time? I can make excuses…I was rushing, but aren’t we all, all the time. I was clerking, when actually I was supposed to be on ward cover…but if I’d been doing that I would have been just a busy probably. You know, I can’t see how this could have been avoided. Not unless there was some way of linking the x-ray to the specific NG tube insertion. How could you do that?

Susan: His son came in, sat with him as he died. We didn’t send him to intensive care, he would never have survived on a ventilator. I explained how food had got into his lung, and he didn’t asl me how, or why… he didn’t assume a mistake had been made. And it wasn’t the right time to go into all the details then and there. He had to have some time to grieve…I think that’s reasonable. We didn’t hide anything.

Mary: I felt awful. I set up the feed pump. As soon as I turned it on the feed began to drip into his lung. I did that, I can’t get way from that. But should I, personally, have checked the tube was correctly sited? I don’t think so. I’m not trained to look at x-rays. Martin, the doctor, told me it was fine. I can’t do more than that…can I?

Martin: Because he wasn’t actually my patient I didn’t find out until the following Wednesday. The registrar on the stroke team came to find me, and let me know. She told me there was bound to be a complaint. I asked her straight away if the family had been told. I volunteered to tell them…but she said it would wait, and that their team would deal with it. But she did advise me to write everything down, all the details, in case I ended up giving evidence to the coroner. I went home and typed up a narrative… I still have it.

The clinical director: The simplest, harshest analysis is that Martin was negligent in not confirming that the x-ray he saw related to the new NG tube. If he had taken note of the time on the screen he would have realised immediately. But I’m sympathetic to his explanation. There was duplication. Two x-rays requested in a short period of time, less than 24 hours. Perhaps, just as we highlight and take special precautions if there are two patients with the same surname on a ward, we should highlight if two tests are arranged for the same patient…to ensure the right one is looked at. This terrible event has exposed a weakness in the system. I have never heard this happen before, anywhere. So it’s hard to say to the family, yes, we made a terrible mistake and did badly by your husband and father…we did, of course, but I cannot see where we could have done better on the night in question. The mistake was there waiting to be made, all the time. It could have been anyone who made it. We now need to look at ways of making sure it never happens again.

The Board (a representative): We were all agreed, we needed to tell the family. By the time we discussed it the initial investigations had been completed, and it became clear that the family had no idea that a mistake had been made. That made it more difficult than if they had been told straight away. It came as a complete and utter surprise to them, to the son anyway…he was the main contact. But even then there was no anger. It won’t always be like that obviously…but this family were philosophical, and took the view, very reasonably, that medical interventions come with inherent risks. We do not necessarily take that view – feeding through a tube should not be risky. That’s why it’s a ‘never event’. It is avoidable.

The family (his son): The Trust were candid with us. They called me, invited me in for an interview, and the consultant explained what had happened. Although I had never heard of Never Events, I realised once they admitted to us that it was food in the lung that killed him that this should never have happened. It’s basic. But I read their investigation, and I can’t see who or what to blame. The poor guy who saw the wrong x-ray, his is probably the greatest responsibility. But if I blame anyone I blame the Trust…did it go over how crucial it is to double check the time, did it train its junior doctors for that situation? Perhaps they should train nurses to read these x-rays, I don’t know. You might think that’s an over reaction, but this was supposed to be a ‘never’ event…and it happened. By definition therefore, inadequate preparations had been made. They hadn’t thought it through…not until my father died.

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