Everything Counts in Small Amounts - Natalie May at DFTB17

Hinweis der Redaktion

1. It has been a busy night in the adult Emergency Department and when I turn up at 0800 most of the beds are already full. I take a handover from the exhausted night team, thank them and send them home.   Thankfully, there aren’t too many new patients waiting to be seen yet. The junior doctors of the day team can see them – I decide the best use I can be is to do a face-to-face ward round of all the patients from overnight who are waiting for beds.
2. When I reach his bedspace it is empty – he’s not there. The sheets lie crumpled, the dripstand holds a small infusion bag of something but is connected to nowhere - the patient is gone. I ask the nurse where he is – in the toilet, he tells me, and then he shoots me a look. In the distance I can hear the sound of retching and I think I see the nurse roll his eyes.   “Tell me about him,” I ask.   The patient is 62, relatively young I think to myself – still working age. The nurses know him well – too well. They do not get on, the nurse tells me, but I can tell this already from his tone and his body language. The paramedics don’t like him either – he’s rude and he’s difficult.   “And he has chest pain?” I ask, recalling the handover I’d already received.   “Yes,” the junior doctor chips in from the desk where she is finishing some paperwork before she heads home, “he has cardiac chest pain – he gets it about once a week, and he always calls an ambulance and then refuses to go to the centre where he can have PCI. So what are we supposed to do? They won’t even take him up on the cardiac ward, the nurses can’t stand him up there. And he refuses to go to coronary care. Usually he just self-discharges, so I guess we are waiting for that.”   “He has morphine at home too,” the nurse says with a sigh. “I don’t know why he even comes here.”
3. Then the toilet door opens and I see him in his gown, his face like thunder. I steel myself, wondering why I didn’t just stay out of it. My heart sinks and I think about how much I need another cup of tea or something stronger – and it’s not even 8:30 yet.
4. I don’t feel this way very often in the paediatric ED and I think that’s because things there are different. Even when there are children everywhere and the cacophony of stereo screaming has reached that pitch where it cuts into your very soul, someone will be smiling – usually the 6-month-old, looking over her parent’s shoulder and catching your eye.
5. The patients we see there are different.
6. Our patients are afraid – we recognise that fear and we know it will make everything we do harder. So we take time to sit down, to smile, to talk – and more importantly, to listen. We address that fear with communication and explanation.
7. Our patients are small, so we think about our treatments carefully and we tailor them to the patient in front of us, based on weight and age and need. We approach analgesia holistically, because it’s not easy to just stick in a cannula and give 10mg of morphine – and in most cases it’s not appropriate either. But we recognise the role of other modalities like splinting for fractures. We approach other treatments more flexibly too – with icy poles and ice blocks, fruit juice and ice cream for the children who don’t want to eat and drink even though we need them to.
8. Our patients are innocent – they come with a clean slate. They don’t make assumptions about the world and we rarely make assumptions about them – we don’t see the aggressive, hostile, frequent attenders and labels among our patients are rare. And when behaviour is bad – we are forgiving without them asking us to be.
9. The culture of the paediatric emergency department is different.
10. We focus on the family. We see a child and we expect there to be other family members present – and we go beyond acknowledging their presence, we take time for them too. We sit down, we introduce ourselves to everyone and we engage everyone in the room, including other children. We embody these key aspects of good communication and we do it without a second thought.
11. We are holistic in our approach – we understand Maslow’s hierarchy of needs and it sits at the centre of the care we provide. We ask about food, about sleep, about toileting – about love. And we provide and support these things, readily, placing appropriate emphasis on their importance. We go out of our way to avoid waking sleeping children. I’m not sure we can say the same about adult patients.
12. We are humble. We recognise that there is no room for arrogance in the paediatric ED, because every so often a patient we have seen with a viral URTI comes back with Meningococcal sepsis. Although sometimes the illness and injuries our patients present with are minor, we recognise that it can be difficult to know for sure – that they, like us, are constantly learning. We know we cannot dismiss the concerns of our patients and their families because we have seen that we can be wrong, that things might change, that disease can evolve, that we will get burned. So we tell our patients it’s ok to return if they are concerned and we validate the concerns that brought them to us in the first place.
13. The staff who work in the paediatric ED are different too.
14. Our staff see our patients’ frailty – we see the vulnerability of children and this helps us see them as people, which breeds a can-do attitude. I’ve seen tertiary specialists “passing by” the paediatric ICU at 10pm and call in, just to see if we need them for anything, as they are on their way home. We don’t usually have to argue with our specialty colleagues about the need for admission: “I’m concerned” or “the parents are concerned” is usually enough.
15. Our staff are kind; our staff regularly go the extra mile – we readily consider the needs of our patients and we are creative about the ways we can address them. We aren’t afraid to challenge “the way things are” if we have a better or more appropriate solution, as you’ll know if you’ve ever suggested a 16G cannula or an arterial blood gas on a paediatric patient – even one who is bigger than I am. We use the illusion of choice to help give some power back to our patients on the rare occasions where we struggle to find more than one way to do something – we might offer the child a choice between sitting on a parent’s lap or on a chair for blood tests we consider unavoidable. We give children time out when we feel we have been inflicting more on them than they can cope with. Our staff recognise that everyone has a limit.
16. Our staff understand the world of children – they inhabit that world and they make an effort to speak the same language even though it isn’t their own language. We adorn the walls and the ceilings with pictures of characters who mean nothing to us because we know they matter to our patients. With older children and young people, we recognise the evolution of identity and try to offer as much self-determination as possible. Our staff understand that ED experience predicts behaviour at the next attendance and they are invested in making that experience as smooth as possible.
17. The paediatric ED is different. You are different, and what you do is different.
18. I wanted to take this opportunity to thank you for all you do. It is the care you deliver in the paediatric ED and the way you deliver it that makes me a better doctor to all my patients.
19. Because as I stand there, facing this angry man, I wonder for a second how differently he would be treated if he was a few metres away down the corridor in the paediatric ED and a few decades younger. So I decide to try it.
20. I smile at him; his expression doesn’t change. I introduce myself and offer a hand for him to shake; he takes it begrudgingly.   I start by asking what we have done for his pain; “nothing,” he says, gruffly, “they can never get a cannula in so they just leave me here with nothing.”   I frown. “That’s not good enough,” I agree, and I believe it. “We have some options. I’m pretty good at cannulas as I am a children’s emergency specialist too – so I can usually get a line in pretty much anyone. I can get you some local anaesthetic if it looks like the best option is in a sensitive area – we can inject some under the skin or use some cream although the cream takes quite a bit longer to work. Or we have some other options – we could give some fast acting medicine up your nose, without needles, while we wait for oral medication to work, or an injection into your muscle – whatever you prefer. And we can get some GTN for you too, to go under your tongue as a spray or as a tablet that’ll melt between your lip and your gum.   Or we can work our way through these options until we have your pain under control.”
21. He gives me some side-eye. “I’m still vomiting, they’ve done nothing about that either.”   “Well, we could try an ondansetron wafer – it melts in your mouth and works pretty quickly. Or if we are going for the cannula I can give something through there, but we could get the wafer first. Alternatively, we could give an injection of some anti-sickness medication under the skin.”
22. A few minutes later, with a cannula in and some analgesia and anti-emetic administered, he softens slightly.   “I’m sorry,” he says, “I know I’m difficult and grumpy. But the pain is awful and no-one seems to want to help me. I’ve been here all night and I haven’t been able to sleep or keep anything down.”   I take a deep breath and decide to be honest with him.   “I think it’s hard for the staff because they think they know what you need – to go to the cath lab – but you have told them you don’t want to go. I think they find that frustrating, that they see that as the way to help you but that you don’t want it.”   “It’s not that I don’t want it,” he says, “it’s that I know it won’t help me. I’ve already had stents in every vessel they can stent. What I need is a bypass. But…”
23. And he pauses. And then I see the tears in his eyes.   “They tell me the mortality is 3% from the bypass operation. That’s not nothing. That’s one in thirty. And my older brother – he’s dying. He has cancer and he doesn’t have long, only a few months they say, but how can I risk dying before him?   He’s looked after me my whole life and he cared for my mum when she was sick – and now he needs me. If I died, who would look after him then? I couldn’t do that to him or the rest of my family. So I’ve told my cardiac surgeon I have to wait. But the pain still happens. I can’t stand it when it does and I can’t take the morphine I have at home because the pain makes me vomit it back up before it starts working. I call for an ambulance and I hope they’ll help me – but when they see my name and my face we just start the same cycle again.”
24. And suddenly I understand. Here is a patient,
25. he is afraid, of loss, of pain and of death,
26. and up against the healthcare system he is certainly small,
27. He is suffering because we have made assumptions, because we have assumed he’s not innocent.
28. He too is a person, a part of a family. He is a man who loves and cares for his brother and his family has its own culture – one in which being there for each other is the most important thing, more important than your own health.
29. We haven’t approached him with a holistic mindset – we haven’t met any of his needs at all. He hasn’t eaten, or slept, or felt loved.
30. He is a man with significant health problems, an unhealthy heart waiting to catch us out - we have failed to be humble.
31. We have overlooked his frailty because he expresses it through anger.
32. He is a man who is in pain, both physical and emotional; he needs us to be kind.
33. His interpretation of risk, of the language being used, is not the same as ours – we have not tried hard enough to understand him. All of his hostility, and negativity, and anger comes from a place of fear because he too is vulnerable. He is a patient, a child and a parent - and he could be any one of us.
34. I thank him for his honesty and I sincerely apologise for the ways we’ve let him down. At his request I bring in the nurse and junior so he can apologise for his grumpiness with them. With his permission I explain a little of his context and they are surprised but immediately the atmosphere in the room is different. We are humbled by his readiness to apologise now that his symptoms are controlled, and now that we understand his needs better we can address them – he is brought some breakfast and another blanket and we turn down the lights so he can finally get some rest.
35. One bee can visit 50-100 flowers in one collection flight and pollinate up to 2000 flowers per day over an area up to 3 km from the hive. A strong colony can fly the equivalent of the distance from the earth to the moon every single day. The difference we perceive between adult and paediatric medicine is an illusion. The patients aren’t all that different and neither are our staff, so why do we act so differently? The culture we live out in our departments can totally change the care we deliver. Just like a bee, the effect of your attitude and behaviour extends far beyond your department. The reach of our collective impact is far greater than we understand. This patient changed my perspective and I hope he helps you to change yours.
36. I’d like to end with some questions for you to think about.   If you don’t do these things, or think this way, when you see paediatric patients, why not? If you don’t do these things, or think this way, when you see adult patients, why not?
37. What one, small, attitudinal change can you make tomorrow to make the hospital a happier place? And if you are a twitter user I would really like you to commit to that by tweeting me with the change you’d like to make at the end of this session. (?)
38. Because when it comes to patient experience and compassionate care, everything counts - even in small amounts - and we can bee the change that makes it happen. Thank you.