Month: December 2017

Dodging shadows: the mysterious art of detachment

 

I watched a patient die before Christmas. He was surrounded by the full crash team, which nowadays is a fairly large group. As the attempt was abandoned, and another consultant ‘called it’, I withdrew into the background. There was nothing I could do to help. I walked away to prepare my departure for the week-long break (lucky me, most doctors don’t get that), and couldn’t help but think about him. His death. I wondered how it would affect me as I arrived home. The family were looking forward to seeing me, my return would mark the beginning of the ‘real’ holiday. I wanted to enter the house with a light spirit and smile. Yet, the image barely fading on my retina, and still vivid in my visual memory, was of a dead man.

How to separate the intensity of that memory from life outside the hospital? Detachment. That is the word, the process. An ability to cut the lines of emotion that stretch from the wards though the sliding doors, along the train track or the A-Road or the cycle lane, thin but tenacious like the silk spun by a giant spider of Middle Earth. Pull as hard as you like, they don’t snap. Yet, to avoid darkening our homes, they do need to be cut.

Detachment. This process has received a bad press recently. The surgeon who burned his initials onto a living liver was defended by Henry Marsh, who used ‘detachment’ as a justification. Detachment can impede our ability to sympathise and to emphathise. In this example, it permitted transformation of a patient in an object to be signed. Any detachment we achieve on leaving the hospital or the surgery, has to be reversed when we re-enter the building.

So perhaps it’s not detachment that is required. Perhaps it is management, of bad or upsetting memories. By this I mean the ability to live with them. Compartmentalisation. Reduction. Or temporary blindness. A method by which negative emotion can be pushed to the margins of our minds, while the lives of others who have no knowledge of the patients, and therefore cannot truly ‘care’ except in an abstract sense, proceed uninterrupted. Silence is one option. Yet this requires the healthcare worker to conceal his or her thoughts and behave normally. This means acting, and the dissonance between inner reflections and external actions could, in time, be harmful. I have no reliable answer. My own method, as readers of this blog will know, is to turn a thing over, look at it from several angles, and process it through words. That doesn’t work for everyone (there would be far too many blogs!).

My final answer is this: doctors and nurses will always bring the memory of death into the home. To leave it on the street is unrealistic. To bury it is harmful. To talk about it incessantly is unfair on those we live with. The only other option, perhaps, is to develop a special facility – to carry the emotional load with as much sadness and respect as death deserves, while simultaneously accepting that the lives lost do not intersect with those who are close to us. The sadness is of a different quality, with a translucence and impermanence that alters us but cannot rob us of normal social reflexes, or the ability to enjoy ourselves.

 

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Avoiding the question

Many doctors will have heard the statement, ‘If I had my way, I’d just have an injection and be done with it.’ Sometimes, it is formulated as a question; ‘Can’t you just give me something to put me out of my misery?’ Or the frustrated appeal; ‘Why you don’t let me take a pill and end it all, I don’t know.’ These patients are, on the face of it, asking for physician assisted death (PAD). When I hear this, it is usually from patients who are not terminally ill, so would not qualify for PAD even if the last proposal to parliament had passed into law. More commonly, it is from older patients who remain cognitively sharp but physically debilitated, and in some discomfort – a degree of chronic pain, but to an equal degree the indefinable discomfort caused by each and every day being a trial. Sometimes, I do hear it from patients with terminal cancer.

When I hear those words, what do I do? I play a straight bat; ‘I’m really sorry to hear you say that.’ Then, ‘But as you must know, it’s not legal here.’ The response of the patient is often a shrug, and a slight turning away of the head. They knew it would go nowhere. It wasn’t even a serious request. In fact, they are embarrassed to have put me in a difficult situation. ‘I know doctor, don’t worry.’ I then proceed down the conventional route, making sure that their needs are being met as well as can be. Is there a referral to palliative care? What does the GP know? Is there clear evidence of depression? (Impossible to tell in a clinic visit, unless their affect is so characteristic a non-psychiatrist can perceive it.) But the turning away of the head is a sign, that we will not connect at the existential level to which they wanted to climb.

The consultation continues. We keep to the ‘safe’ areas. But the thing they really wanted to talk about, and which they knew would not be entertained, goes unexplored. For what is the point of talking about it, when there is no chance that it can be achieved? Best, really, to leave it unsaid. To challenge, or ‘manage’ their conviction that it is preferable for life to end, would be like trying to correct wrong-thinking. ‘Surely you don’t mean that… perhaps we should look into your mental state, see if you are depressed.’ Or, ‘Are you sure you’re not saying this because you don’t want to be a burden on your children?’

I have previously considered how doctors might respond to comments like this, if as in Canada, PAD is legalised. In that case, the hastily asked question will no longer be ignored. It will signify a concern, a need, an agenda that cannot go unpursued. To ignore it would be to deny the patient access to a medical intervention that they have a right to access. To ignore it would be to allow the doctor’s personal distaste to redirect the patient’s agenda.

Whenever I hear the question I reflect that in this area, as in no other, our responses are restricted by the law. If and when the law changes, the tenor of the consultations in which the question of PAD is introduced by patients will change. A natural dialogue will take place. The patient’s true agenda will be explored. For now though, the coyly delivered question can bring no meaningful reply.

 

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Systems and sense

 

 

The controversy surrounding paediatrician Dr Hadiza Bawa-Garba has got me thinking about the relationship between individuals and systems in healthcare. In this case, it has been suggested that system failures, including under-staffing, contributed to a young patient’s death. So important do those factors appear, many feel she should be allowed to continue practising despite a prior manslaughter judgment against her. How do we decide how much blame resides with an individual doctor, and how much can be attributed to the sub-optimal system? I do not know the answer, but it is a question worth exploring.

I cannot recall a single avoidable death where the ‘system’ (i.e. processes, ways of working in the hospital) was not at some level criticised. This is because I have yet to work in a hospital where safety-netting systems were perfect. From slow or inconsistent IT, to lost correspondence, inadequate hand-over arrangements or over-stretched teams… there is always something in the background that appears to diminish an individual doctor’s ability to make the right diagnosis, or initiate the right treatment, in an acceptable timeframe. That’s why it is rare for investigations into avoidable deaths to conclude that a single person’s act of commission or omission was to blame. Blame, of course, is a word we avoid, though as I explored in a previous article, a sense of personal culpability may be important as a driver of self-improvement.

Thinking back to formative errors I made in my own training, I recall an incident of gentamicin induced renal failure. I prescribed it on a Friday, handed over the job of checking the levels (it is toxic if it builds up in the bloodstream), and went off for the weekend. The patient was given it as prescribed (this was back in the day when dosing was written up regularly, but with the caveat ‘check trough levels first’). But no levels were checked. Her renal function deteriorated, and she ended up on dialysis for a while. Disaster.

The system did not help me. There was no gentamicin prescribing protocol; no system of flagging abnormal kidney results to doctors on call; the handover book was a scrawl – so many ways in which better systems could have helped prevent harm. Yet, that was the environment in which I worked. It was my handwriting on the chart that damaged her kidneys. I learned that if a result is important, you need to chase it, and if something needs doing when you’ve gone home, you have find out who is supposed to do it and make sure they are completely aware. You can’t be passive; you can’t leave it to the system.

Take this example, from a Human Factors in Healthcare document. I have underlined the areas where it was felt the system let the patient down, and put into bold those where an individual made an error.

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A child with a known penicillin allergy was prescribed and administered an intravenous dose of an antibiotic of the penicillin class’

A child was due to have a pacemaker fitted. On pre-admission an allergy to penicillin was recorded. This was noted on both the nursing admission assessment form and the anaesthetic record chart. Prior to operation, the allergy was discussed with the specialist paediatric cardiology registrar, the consultant paediatric anaesthetist, anaesthetic specialist registrar and the cardiology consultant. However, following the procedure the patient’s plan included intravenous and oral penicillin.

How did this happen?

  • Intravenous penicillin is the usual antibiotic used following a pacemaker being fitted. There was no up-to-date protocol on what other antibiotics should be used if a paediatric cardiac patient has a penicillin allergy, which initially caused confusion;
  • There was no clear record of the allergy in the medical notes when the Consultant Cardiologist advised treatment;
  • No system was in place to prevent penicillin prescription when a known allergy was recorded.
  • A number of appropriate checks were not followed prior to administration of the antibiotics.
  • During independent checks, neither nurse checked allergy status, and both were under pressure to complete tasks. The patient’s allergy band was on the same side as their identity band, both of which were covered with a bandage for an intravenous drip.

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Imagine the child had received penicillin and died from anaphylaxis. Would it seem reasonable for any of the individuals involved in the actions highlighted in bold to have been blamed, censured, or worse, accused of manslaughter?

The cardiologist put penicillin in the post-op plan, despite having been told about the allergy. Neither nurse checked for allergy, not thinking to peel back the obscuring bandage. Somebody put the bandage on without moving the allergy bans. All were at fault. But, an electronic prescribing package that automatically pulled the allergy from the patient’s record and blocked any doctor from writing up a penicillin-related compound would have rescued the situation. Can the absence of such a system be blamed for an error that results in death? Would its lack be used, in court let us say, to extenuate the error medical staff? Or should staff be judged in the context of the environment in which they find themselves?

At what point does responsibility for errors cease to be attributable to systems, and start to accumulate around individuals? There is no visible line or threshold. Regulators and courts must determine what was reasonable in the circumstances, and if a doctor meets minimum acceptable standards within Good Medical Practise. For the trainee, it is important to understand that all systems are imperfect, and to develop a sense for when to drive management forward, well before the backstops provided by the ‘system’ throw up a red flag.

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Signature

 

What explanation can there be for a surgeon to write his initials on a patient’s liver? It sounds bizarre and disrespectful. This almost surreal, alleged event is sub judice, and I know nothing of the people involved or any details beyond what was in the papers, but perhaps it exposes some interesting psychology.

In the medical specialties that require practical skill, especially surgery, you work hard to become expert. Over the years the movements of the hands and fingers become practised and slick. Operations that appear impossible to the lay-person or junior trainee become routine, yet each patient is different. Each procedure presents its own challenges, hiccups, sudden recalibrations and extempore solutions. At the end of a particularly difficult case, when the patient appears stable and safe, you might sigh with relief, but also experience a surge of pride on a job well done. Congratulations are hard to come by in medicine. The job well done should be the norm, after all. But looking down at the organ, structure, or vessel that now pulses healthily as a result of your dexterity, you might be forgiven for thinking – ‘I did that!’

To mark a job well done with your initials is appropriate in other walks of life – in art and sculpture, in literature, in architecture. The artist owns the piece. A part of them, their skill, their creativity, their experience, lives within its lines.

Can medical procedures be regarded as art? Yes, I would say. The long facial reconstruction, the painstakingly re-joined finger, the delicately implanted heart valve… in the fine skill and seamless results it is easy to identify the hallmarks of the inspired artisan, the committed artist. Perhaps it is understandable that a surgeon who comes to see the results of their skill as art feels the urge to sign it.

However, it is a living body that we are talking about here. What lies under the skin is sovereign to the patient. They will carry it around with them for the rest of their lives. They were born with it. It is wholly theirs. (In the case of a transplanted liver of course, it belonged to another. The act of altruism and donation makes it worthy of even greater respect.) Perhaps that is the line that may have been crossed here – the distinction between what a surgeon can claim to ‘own’, and what is and will forever be sacred to patient.