It is probably over 15 years since the moment I wish I had said ‘stop’
I was in a hospital department – I won’t say specifically when, where or which one, but I was standing with a consultant and we were treating a patient who was experiencing an allergic reaction.
I don’t remember whether this patient had received a dodgy drug, had been stung by a bee or developed the reaction for some other reason.
This patient had a rash, I think her eyes were itchy and her throat raspy; nothing more.
Beyond this level we enter into the territory of anaphylaxis which is a life-threatening response to an allergen – something which causes our immune system to go haywire.
This woman however, I am pretty sure was just being allergic.
I remember the consultant asking for adrenaline which they proceeded to inject intravenously into this patient who as I say, apart from a worried look and nasty rash was OK.
My knowledge at that time told me that intravenous Adrenaline is a very powerful drug – we tend to use it in situations of cardiac arrest i.e. when an individual’s heart has stopped; anaesthetists use it in theatre and the intensive care unit, it is also used in situations of anaphylaxis – that is when, following a peanut or bee sting a person develops shock (their blood pressure drops) and they risk dying –
I hadn’t ever seen it used in a conscious patient with a normal heart rate and blood pressure – nevertheless this is what was administered.
I should have questioned the consultant – asked whether this was the best drug at that moment; I should have asked why the drug was being used intravenously; I should have done or said something. Instead, I just watched, and I guess that is why I haven’t talked about this for so long.
The consultant administered the Adrenaline and the patient stopped being itchy and breathless, their heart rate speeded up and their blood pressure increased; they experienced chest pain, their heart recording showed the rhythm changing with multiple ventricular beats – a potential precursor of cardiac arrest, and they appeared very, very anxious.
The patient survived and recovered.
They could easily have died, not because of the allergy, but from the treatment which even today I feel was excessive and inappropriate.
I am less concerned with the medicine that was used – it is the fact that I watched something I felt to be wrong and didn’t ask or challenge.
In the past 15 years this episode has been one from which I have learned, yet, it is still something, the likes of which I hear about regularly in the hospital.
The most common, and probably the most distressing relates to the treatment of someone who is dying, perhaps in the final days of life.
The majority of us have an inbuilt appreciation for when another person is coming to the end of their life – likely, an evolutionary response to the many thousands of years when death was a much more commonplace event than it is today.
The phenomenon, is of the consultant somehow not reading the signals or misinterpreting what is happening, where they insist on treatment, on antibiotics, blood tests and x-rays, despite the patient’s impending death.
Apparently doctors are in general poor at prognosis in relation to a patient’s life-expectancy – we tend of be over-optimistic; whether this is out of a sense of hope or confidence, I don’t know, but to nurses, particularly those working on wards caring for older people, this is something that is familiar.
Yesterday, at a meeting in Doncaster we ran our first Person-centred care training day.
This is how we have opted to interpret the future of quality and safety training in the hospital; specifically, taking the approach that things very often go wrong when the person – the patient is not at the centre, when their hopes and fears, wishes and dreams are not considered or taken into account; beyond this, we have accepted that regarding the patients and when appropriate their carers or relative as part of our teams and how we decide on care and treatment is fundamental.
The day covered topics such as end of life care, falls, dementia, delirium and how to support people during their time in hospital (beyond the medicines and investigations) – i.e. through meaningful, made-to-measure activity and engagement.
Yesterday, in relation to patient safety, I touched on this concept, one which looks at the hierarchy in hospital and the relationships within and between teams.
This is the same hierarchy which is familiar to those working in the fields of safety and human error – whether in engineering, aeronautics or clinical care; the concept that there is no such thing as a stupid, daft, or, wrong question – in fact, the only question that is wrong is one which isn’t asked.
People are sometimes fearful to ask a questions as it may reflect poorly on them – with the belief that they are the only person who doesn’t know something; this is a very human behaviour and one which I suspects relates to the Spotlight Effect (see Barry Manilow T-Shirt experiment), it is also supported and reinforced by hierarchy, where only A can talk to B who can talk to C – to A, C lives in an exalted place, to C, A doesn’t exist (a little like the characters in Neal Gaiman’s Neverwhere).
Hierarchy in healthcare is both toxic and part of a yesteryear which has no place today.
This is what it means to work in multidisciplinary teams – these are not just weekly meetings where people stick to their well-worn scripts and behaviours (within a hierarchy), but, the way teams need to exist and function all the time in every situation, with an awareness of the complexity of care and the reality that one person can never know everything;
This is not to diminish the importance of leadership in teams – the leader, in hospital, the ward manager or the consultant, still needs to assume responsibility for failings and lead the celebration of success, the means of arriving at decisions must be through the communication of a team who is not afraid to ask, reveal their ignorance or lack of understanding, who are confident that by making themselves vulnerable, they will be praised and appreciated, not attacked.
Back to my experience with the patient –
She survived. She could have died – I never asked the question.
I was more worried about making myself look foolish than protecting a patient; my ego got in the way.
And, ego is an incredible obstacle to team working, patient safety and leadership – when your profile comes before that of another, things don’t work.
I believe I have learned from this experience; I think I work with the team, as a collaborative, sharing ideas, information and knowledge.
We need to grow these concepts, ensure that they are central to everything we do not just in health and social care, but in every walk of life.
The next time you don’t understand, the meaning is unclear, the venue, wording or intentions vague, ask.
And when the situation might risk harm, start with what we call mitigated language – ‘Erm, excuse me, do you mind, sorry…’ as we are very good in the UK, and move to more direct language if that doesn’t work.
Shout if you need to!