Month: December 2013

Switching off

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Map from website ‘Strait through: Magellan to Cook and the Pacific’

It was the day before Christmas. Matt was an FY2* working in an acute Trust. His registrar explained,

‘Our job, today, is to set a course for each of our patients, make sure their treatment is right, resuscitation and escalation decisions considered, frequency of reviews agreed and handed over…’

‘We’re only away for a couple of days.’

‘I know. Easter is worse actually. But the hospital won’t be running at full tilt between Christmas and New Year, and I’m taking one day off, Suzy’s seeing her family in the States – she was lucky to get that agreed but her Mum’s ill I think – and for good or bad, it’s the sickest ones that will get most of the attention. So go to it! I’m in clinic, but I’ll check in afterwards.’

Matt and the FY1 saw everyone and made clear plans, but late in the day he picked up a few complications and serious developments. He left at 7.45PM and found the roads deserted. Most workers were home already, but he had a three hour drive ahead of him. As he drove he thought about two patients for whom he had prescribed new treatment, one with pneumonia, the other with renal failure and dangerously high potassium levels. It was still quite a novel experience for him to make a firm diagnosis and start treatment without direct supervision, but by quarter to eight on Christmas Eve the wards were not exactly overrun with seniors. To be fair, at 6.30PM all had seemed settled, and he had said goodbye to his registrar with confidence and goodwill!

When he woke up on Christmas morning, in his parent’s house, the first things to enter his mind were the two patients he had treated just twelve hours before. Both should have been reviewed at around midnight, the one with renal failure requiring a repeat potassium check, the one with pneumonia a blood gas. Matt had handed both tasks over, but he was concerned. When he made the hand over call, the evening SHO was being gradually buried in last minute requests as each team tried to leave for the holidays. Matt went downstairs and joined his two siblings, one older and one younger, and his parents for breakfast. This would be the last year that they spent Christmas together – there were babies and partners and houses and grown up comittments coming. He enjoyed the meal, but the thought of the renal failure patient kept nagging at him. He must have appeared distracted, for his father commented,

‘What’s on your mind son?’

‘Oh, nothing…work.’

‘Well, you’re off now aren’t you. The poor sods who are in today can deal with it.’

‘Yes…but…’ and he didn’t go into it. His father was not in healthcare, he had been a sucessful businessman who’s company seemed to shut down entirely for two weeks over Christmas. Matt remembered that he had brought work home for the holidays, and, thinking about it, there must have been worries and concerns that niggled even though the doors were closed. But his father had always hid them well, committing himself fully to the time the family spent together. Perhaps Matt had to learn the skill – that of closing out his professional life for a couple of days and appearing relaxed. Perhaps he would learn not only to appear relaxed, but to be relaxed!

They had lunch, and the two glasses of Prosecco spurred him into a mood a convivilaity, but as he sat down on the sofa at 3PM and let his eyelids fall, a fluorescent green line flashed into his mind’s eye and scurried across the dark field. His renal patient, in cardiac arrest! It was now time for presents. Again, he must have put on a poor show, because his sister took him to one side and asked,

‘What is it? You look miles away.’

Matt told her. She was unimpressed,

‘It’s not your concern. You’re off now. Come on…’

‘I’ve got to know what has happened to him.’

‘You’ll find out when you go back won’t you?’

‘I suppose so.’

He went back into the lounge, but fifteen minutes later said he was going to the loo and went upstairs. Covertly, in a whisper, he used his mobile phone to ring the hospital switchboard. He waited eight minutes and 47 seconds (his mobile display ticked over silently and patiently) to get through. He guessed that many relatives were trying to contact wards to check that their interned loved ones were alright. After another five minutes the on-call house officer answered her bleep. Matt asked her if she had seen his renal patient. She hadn’t.

‘Hang on…’ she said, ‘I’ll check the computer for something, the name rings a bell.’ A pause, keyboard taps. ‘He’s on intensive care. Oh yes! I remember, I heard all about it when I arrived this morning. He was reviewed at 2AM and his potassium was over seven or eight something…the house officer on overnight called ITU, they came to see him, and an hour later he was on a filter. He’s fine. Good job he was reviewed. Could have done with being seen a bit sooner probably…his ECG was horrible, they think he was two hours away from arresting, he was so acidotic too. Was he your patient?’

‘Yes…I arranged the review…’

‘Good thing you did…’

‘Thanks. Thanks for answering.’

‘Why are you ringing, it’s Christmas day?’

‘I just…wanted to know…’

‘Relax man! We’ve got it covered. Go and get drunk.’

And he did. Later he dreamt of ships arriving in harbour, their cargo safe, all hands present.

* FY2 = doctor who has been qualified for 1 year

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Hollow heroes

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Artist unknown, photo taken in Covent Garden market 14.12.13

Justifiably or not, young doctors are inspired and motivated by the thought that they might, one day, save somebody’s life. Opportunities come rarely, but spend long enough in a hospital and one day you will find yourself in a situation where a single action (be it a procedure, a prescription or a revelatory, previously un-thought of diagnosis) will stop a patient from dying in front of you. You cannot help but walk away immensely pleased, brimming with adrenaline enhanced satisfaction.

Some would say the temptation to wallow in a bath of warm aggrandisement is self-centred. It may encourage a too narrow perception of the clinical encounter, diminishing the suffering or fear felt by the patient and magnifying the importance of the doctor. For after all, who really matters here, you or the person who’s life has been saved? But I would defend the doctor who excitedly recounts such an episode to a friends or partner by inserting themselves in the lead role, because to suppress that pleasure, and take the puritanical view that ‘it’s just my job, it means nothing’ would be to deny doctors access to a very important source of job satisfaction. However, experience has told me that there is a quid pro quo, one that is revealed when things go badly. We must ask ourselves – how happy are we to take the lead role when our actions or omissions contributed to suffering…or even death?

My SHO and I (a registrar at the time) were called to see a patient with cirrhosis who had started to vomit blood. We resuscitated him, decided it was safe to take him down for an endoscopy, and within half an hour we were watching the varix spurting blood across the field of view on the monitor. I fired two bands, the bleeding stopped, and the drama was over. My SHO looked across, still squeezing the second bag of blood and clearly impressed, and said,

“You just saved his life.” What impressed him, I think, was not my specific role in this, but the fact that a procedure could so swiftly stabilise a patient. The experience would prove a clincher for him…he had been thinking about choosing this specialty and the opportunity to perform heroics, like this, was just what he needed to witness.

But as we walked back to the ward I began to explain,

“It’s not me, or us, who saved him. If we weren’t here today there would be another registrar, and another SHO, who would have found him and ‘scoped him. The chances are they would have done just as good a job.”

“But it was you. You made the diagnosis and sorted everything out.”

“But those were not exceptional actions. They are just what you do in those circumstances.”

“You may as well give yourself a bit of a pat on the back.”

“I am, internally, because I’m glad we made all the right decisions. But what we did was normal. We are working in a system that is designed to allow us to find patients who need us to apply our training and skills, so really it’s the system that saved the patient. Not us personally.”

“So you don’t get any fundamental satisfaction from that?”

“I do, but I have to put it into perspective. So do you. Try this. Imagine we had got the patient down here…no…imagine YOU were the registrar and had got the patient down here. And imagine you were doing the endoscopy, found the varix, but messed up somehow. You didn’t set up the banding kit properly, or you chose the wrong place to band. And he kept bleeding. Then he vomited blood and aspirated, then had a respiratory arrest and died in front of you. How would you feel?”

“Awful.”

“And would you blame yourself?”

“Yes.”

“Really?”

“Of course I would, if I messed up.”

“Up to a point. But I think I know what your mind would do. Everybody does the same. You feel bad, you go home, you think on it, you talk to your mates…then you rationalise. — He was in a high risk group — The endoscopy nurse should have told me the banding kit was not set up correctly — In fact she should have set it up anyway — There wasn’t time to arrange anaesthetic support — The varices must have been under high pressure — These patients, what do they expect when they drink all their lives? –…”

“I would never think that.”

“The mind can go to some dark places when you feel under threat.”

“I wouldn’t just rationalise it away.”

“Perhaps, to some extent, just to keep yourself functional. My point is, whenever you are tempted to congratulate yourself on a job well done, imagine how prominently placed you would want to see yourself in the scene if things hadn’t gone well.”

“It sounds very joyless.”

“A bit. My advice is, enjoy the satisfaction, but don’t talk about it. Because fate has a way of arranging things so that after every example of brilliance or skill, something comes along to bring you straight back down to earth.”

oOo

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Introduction to Spoken/Unspoken: hidden mechanics of the patient-doctor relationship

Since publishing the last collection of posts in Motives, emotion and memory – exploring how doctors think I have asked myself – where am I going with this? What is the common thread?

These posts came from a desire to explain how doctors arrive at medical decisions. They required a degree of honesty and a willingness to enter into uncomfortable areas of human motivation. For instance The moment: a tale of three doctors focuses on the place of reputation when considering how actively to advocate for a patient, and The eyes and the ears: why Adam blew the whistle (a sequel to Why Michael didn’t blow the whistle: pub scene) exposes the personal concerns that are balanced against the right course of action. In Signals: the language of uncertainty I look at the way doctors try to communicate their fears for patients without actually saying so – a form of self-protection. Overt self-preservation from the emotional challenges that a career in medicine presents lies at the heart of Too close: from empathy to over-identification and The needle and the damage done. Rainstorm (the most popular so far as judged by ‘page hits’) imagines a demotivated junior doctor on the brink of resigning. Why? The thickening atmosphere of direct accountability in the post-Francis Report, post-Mid Staffs era. He must learn how to function in a world where errors or omissions can no longer be ignored with a ‘that’s just how things are’ attitude.

But an inquiring approach to the medical mindset does not explain the posts in which I tried to imagine what patients might be thinking, such as Signs, Don’t tell me the odds or I hear you. These are complete fictions, as I have never been a genuinely ill patient at risk of death, and I have never been trapped in bed unable to communicate. But nor have most doctors (especially young ones) so the value of these exercises in imagination, or ‘hyper-empathy’ might be in demonstrating how we believe they respond to the day-to-day challenges of being on the ward. They are also valuable in demonstrating how far doctors can go in trying to understand what their patients are thinking as we interact with them; do they see through our prevarications or justifications for delays or errors?

Then there are the reflections on chance and hazard. Intersection looks at how patients who never see or know each other can influence each other’s clinical progress. Fate night examines how a young doctor’s social plans are scuppered by a series of unfortunate events, such that she must decide whether to stay or go, and A night in the system shows how a relative must assert herself to make the apparently oblivious, disconnected machine that is a hospital work for a patient.

As in the last volume I have written longer pieces on practical medical ethics that reference freely available resources on the internet, such as The cusp: ethics of the learning curve, Blaming patients: a very human temptation and Substitutes (which is about who we ask when trying to discover what incapacitous patients would have wanted.)

Finally there are several more political pieces, an arena in which I do not feel very comfortable as a doctor who spends more time looking down at the individual level than across at the societal level. Nevertheless, Journeymen: why aren’t doctors more loyal to the NHS, Precious: a legacy of understaffing and NHS2 in year 2053 are honest reactions to recent events.

So, returning from that quick tour, where am I going with this? The answer is…across a divide. That is my ambition. In An opaque code: the Liverpool Care pathway and a gap in perception I discuss the gulf of understanding between doctors and their patients (and their patients’ families) which drives many of the controversies that we see in medical practice. The articles in this book were written to shed light on factors driving the motivations and behaviours that directly affect patients. I hope they are good enough to serve as bricks in the fine bridge that others (such as Jonathon Tomlinson in his wonderful blog A Better NHS, or Kate Granger in her position as doctor, patient and generous communicator) began long before I started writing.

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Rainstorm

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He had sat through the starter and the main course, each morsel sticking in his dry gullet. Opportunities had come and gone, but he had failed to take them, paralysed by cowardice. Nevertheless, his mind was made up and nothing was going to change his course. His mother seemed to sense that something was wrong; the conversation faltered, he declined to have his wine glass refilled.

“What’s wrong love?”

“I’m giving up medicine.”

oOo

A month earlier.

He parked his car and turned off the radio. — ‘…doctors will be criminalised if found guilty of wilful negligence…’ — was the sentence echoing in his mind as he entered the hospital through a side door. He was on-call today, but he hoped to see some of his own patients before things began to heat up. His first patient had been diagnosed with inoperable lung cancer, and their relatives were on the ward waiting to talk to him. David took them into a private room. As he closed the door behind them the patient’s daughter pre-empted him, asking,

“Who are you?”

“I’m David Clark, the SHO.”

She opened a spiral bound note book and began to take notes.

“…before you go on doctor, can you tell me when you found the lump?”

“Well…soon after he came in, when he had the scan…”

“Wasn’t it on the x-ray he had on the day he came to casualty?”

“Well yes, but we, the doctors looking after him them, were concentrating on the infection, but now a scan proved it…”

“That was two weeks ago. I don’t understand why there has been a delay.”

David controlled himself. His plan, the careful steps he rehearsed in order to take the family along an explanatory path of diagnosis, treatment options, arrangements, support…had been blown to bits. Flustered, he continued. Everything was being written down. A phrase from the cop shows rattled in his head as tried to focus on the words, ‘…will be used against you in a court of law…

The day got busier. While he was inserting a urinary catheter he was fast bleeped to another ward. He couldn’t move, committed to the task that he had begun. He hurried it, didn’t do it quite as carefully as he normally would, anxious to leave the patient and rush to the emergency. When he got to the other ward a charge nurse informed him that he had no choice but to fill an incident form. Only the most junior member of the team had responded to the urgent call, and she hadn’t been able to deal with the emergency.

“But I was tied up, I couldn’t come…’

“I know doctor. But we have to do these forms. Otherwise nothing changes, does it…?’

He imagined his name in the text, the focus of culpability. In the Acute Medical Unit ward he received a call; the bed manager had been trying to find him. There was a patient on an outlying ward under his team’s care who had not been reviewed for four days. Although David was mired in emergency admissions by now (enjoying the rapid throughput of fresh cases, stimulated by the need to make fast decisions, arrange investigations and take responsibility for the treatment plans), he dragged himself away to visit the lost patient. She was very elderly, evidently succumbing to pneumonia on a background of heart disease. In fact the admitting team had done a very thorough job. They had spoken to the family, discussed resuscitation, introduced the idea of palliative care, but then…nothing. For four days. No doctors. The odd on-call visit to prescribe fluids, but nothing substantive. It shouldn’t happen, but it can and it does. And now her son was here, visibly upset. David introduced himself. The son retorted,

“I want an explanation!”

“I’m sorry, there must have been a mix up, and then over the weekend…”

“I don’t care. No-one has seen her, she’s been ignored. Who is this?” He pointed to the consultant’s name written in blue marker on the white sign above the bed, “Is he the consultant?”

“She. Yes she is. But your mother has only just come under her care.”

“No she hasn’t, that name has been up there every day. But you didn’t see her on Monday or Tuesday. It’s neglect. What chance she did have has been lost.”

“The nurses tell me she has been comfortable.”

“Yes, she has. But…

David entered the final hours of his difficult day. He made many accurate diagnoses and many good decisions. The consultant seemed happy with his clerking but David was down. He kept thinking back to the old lady’s son, his sharp words. ‘Wilful…’ ‘Ignored…’ ‘Neglected…’ David’s usual spark had been extinguished. His shift was over. As he walked into the doctors’ room to pick up his coat the bleep went off one last time. He called the number.

“Dr Clark. Hi, it’s Mary on Chestnut ward. Mr Threlfall, the man we put out a fast bleep for earlier, he’s died. No, it was expected, your registrar came to see him and made him not for resuscitation. It’s just, because of that incident form earlier, I’m going to send the notes on to the morbidity and mortality meeting for review. As a formality, you know.’

As he closed the door of the office behind him a colleague ran past him in the corridor; breathlessly he shouted,

“Crash call. Some guy who had a catheter inserted this morning, on Warfarin, he’s bleeding out…”

David opened his car door, sat heavily in the seat, and turned on the radio. —‘Police have confirmed a second criminal investigation into a potentially avoidable death in Mid Staffordshire, five years after…’— He turned it off, put his palms on the steering wheel and his forehead on the backs of his hands, and muttered, “I can’t do this anymore.”

oOo

David sat in his consultant’s office. She had locked the door and asked that they not to be disturbed. She had heard about his decision, and started by asking him to hear her out. Then she explored what it was that had made up his mind. He described his shift from hell. She said,

“I’ll tell you what I think. We’ve got to help you adapt to these…stresses. The scrutiny, the incident reporting…”

“You mean just ignore it?”

“In a way, yes. They should not dictate how you function as a doctor. Because they are more visible – after Mid Staffs, after the Francis Report – and because they have imposed themselves on you, you have come to react to them rather than the instincts that drew you into this vocation in the first place. They are important, yes, they are there to protect patients, yes, but from those doctors who might be harmful. You are not one of those doctors. You are good. You should be able to function without bring fearful of running into these electric fences and getting hurt all the time. From what I’ve seen of the way you practice medicine, you will find a path goes nowhere near the edges of reasonable, sensible practice.”

“Yet I seem to have run into those fences time and again. I described it to my girlfriend as living in a continuous rainstorm, where each raindrop is a new patient and a potential clinical incident or mistake that I must protect myself from. Usually I can, using my knowledge and experience, or luck, but sometimes one of those raindrop gets through, and explodes. And I never know which one it’s going to be…”

“What happens to patients isn’t always down to you or your decisions. Some get sick despite everything. You can’t necessarily stop that, so you can’t take the blame. Looking back, did you actually do anything wrong during that day on call?”

“I felt like I did. Incident forms, threats of ‘wilful negligence’! And the catheter. That was my fault.”

“Didn’t you hear? He had a bladder tumour, that’s why he bled! Forget that. And ‘wilful negligence’…please don’t be scared by that term. The relative who used it wasn’t criticising you, he didn’t know who you were. He was frustrated with the situation. Wouldn’t you be? That term, whatever it means, wasn’t designed to be applied to isolated mistakes.”

“But she was neglected.”

“Yes, by our system. And we’ve tried to close that gap. But not by you. You were never in danger. Did you really think you could go to jail? Really?”

“No. Yes. I don’t know. I just kept hearing it…”

“I know. And the incident form…well, they are important, and are used to alert us – the doctors who will be working here for years! – about what needs to be fixed. That wasn’t personal either.”

“I appreciate what you’re saying, I really do. But I can’t work in this atmosphere of…negativity.”

“But it’s just that. An atmosphere. We have to learn to breathe it without taking it personally, without a sense of suffocation..”

“So it’s my fault – this crisis. I’ve got it out of perspective?”

“A bit. That’s why we’re talking. I want to help you understand how a good doctor must accept that they will be subject to what seems like criticism now and again. You seem to be aware of your limitations. In fact you may be too aware, because you’ve grown nervous of them. The warnings and safety nets that have become so much more visible recently are not there to punish you. If you, as one of the great majority of trainee doctors who are good, intelligent and conscientious, are picked out and quoted in some incident form, or referred to anonymously in a mortality meeting, it’s more likely to be a reflection of how stressed the service is, or how fallible a particular system is. It’s not a judgment on you.”

“But if I am a good doctor why am I being reminded about these systems all the time? Threatened by them.”

“There is a temptation to use them as levers, to get you to see patients more urgently than you, as the doctor, might feel is appropriate. Remember, you are the doctor, your opinion is valuable .If you are asked to see someone who is deteriorating, you have the right, by virtue of your experience and understanding of clinical priorities, to decide how soon they should be seen. But if somebody else thinks they should be seen sooner, and they are able to wield a stick, it’s natural for them to do this to motivate you to hurry up. They want their patient seen first – that’s natural. But in doing so they ensure that you are driven by a negative motivation rather a positive one. You fear the situation rather than embrace it. And look where it has brought you.”

“So I just say no, sorry, I’ll come when I want to.”

“If you are juggling what appear to be equally important priorities, yes. But you must explain why, help the person you are talking to understand and, if possible, agree. And you must follow through, see that patient, hold your course, finish each task that you begin, and leave the ward confident that you have dealt with the problem in hand…”

“And when I get called away to see an even sicker patient…”

“Ask, build a picture, make your own mind up. Things don’t happen that fast. The sicker patient will have been deteriorating all night, they can usually wait another ten minutes. If they are arresting you will find out, there will be a crash call. It’s all about accommodating the continuous stream of emergencies, catching the raindrops, without being caught up and carried away in the flow. If you do you will become disorientated. You are the one who needs to keep calm, maintain perspective. It’s you they’re looking to for reassurance. Remember that David.”

“I hadn’t thought about it like that. I’ve just felt…so junior…all the time.”

“Junior in some ways, but senior in so many others…at three in the morning you are the most accessible doctor on the wards. First contact. It’s a massive responsibility. With that responsibility comes respect.”

“Really. I don’t feel it.”

“It comes.”

“If there was respect they wouldn’t have done an incident form.”

“No. You’re taking it the wrong way, personally. The incident form is irrelevant. It wasn’t a judgment on you, it was an observation that when a fast bleep was put out the doctor couldn’t come because he was doing something else. So what? If you can accept that now and again, purely by virtue of the fact that you see so many patients, you are bound to be involved in a complaint or an incident form, you will be able to work naturally, learn, and progress. If you can accept that you work within a network of continuous feedback, but without having your outlook obscured by it, you will achieve whatever you want to achieve.”

“You make it sound almost cosy. It isn’t. In the middle of the night I get shouted at if I don’t come. And relatives write down what I’m saying as though everything is a statement.”

“Well…so might you when you have a relative in hospital. Are you coming back to work next week?”

“ I haven’t decided.”

“That’s OK, take your time.”

______

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