health, Uncategorized

Le Freak

I’ve had total writers block this past couple of weeks which is very unlike me.  In the end I decided to write a list of all the things that I’d been involved with including snippets of conversations.  I find even the most throwaway of comments can spark something.

What came out was largely service delivery related.  Or in other words, staffing and rota work.  Most people would agree that taking on any kind of rota is somewhat of a poison chalice.  It did take a fair bit of persuasion to get me to become involved in the junior doctor one.  However I strongly believed (and still do) that get the rota right and everything else will fall into place.

Now I’m not going to spend the rest of this blog talking about rotas.  However it did get me thinking about other areas in healthcare that seem easy on paper but somehow never quite translate to that in real life.

Take ward rounds for example.  Why is it that doctors seeing the same type of patients can take vastly different times?  It’s not like the problem is all that different or the initial results any more complex. The doctors themselves have been through a generic training scheme.  The paperwork is the same.  So what is different and why can’t you standardise them to do the same thing every time?

Simple – you cannot standardise people.

What I have seen over the years is that people do unpredictable things especially when they feel they are being forced into something or being backed into a corner.

And therein lies the contradiction in healthcare – we are constantly being asked to change things in order to standardise what we do.  The more you ask people to change, the more likely they are to resist and nothing changes.

I also think some people actually enjoy treading water because it’s perceived as taking less energy.  And let’s be honest, it’s familiar territory so is less scary.

In stroke I teach that recurrent, stereotypical events are not recurrent TIA’s.  If you think through the pathogenesis and mode of action you quickly realise that it just doesn’t make sense (there is only one caveat to this with a critical carotid stenosis but I digress….). However it takes a big surge of energy on my part to stop this cycle of doing what has always been done, revisit the history, explain to the patient what it might be (including I don’t know) and coming up with a plan.  It also takes a lot of energy, trust and faith on the patients part to work with you in this.  The sense of satisfaction when you get it right though makes it all worth while.

If you take this example and think about how we apply it to other aspects in healthcare e.g. organisational change, rotas, ward rounds – it becomes easy to see why the same problems/issues recur time and time again.

So what do we need to do?  Well if it was that easy I wouldn’t be writing this and the NHS would be totally fine…. I do think it’s a bit like what the quote says.  Don’t moan about the problem or expect it to change.  Stop doing what you have always done. Revisit the issue. Adjust your sail.  See what happens.

You might just be surprised……


delirium, Uncategorized

Come into my world

What would you like us healthcare professionals to do better?’

The person asked was an older gentleman who had survived several admissions to Intensive Care. On each occasion he suffered delirium.

His answer was simple: ‘come into my world’

For me this summed up the American Delirium Association conference.  It was, in every sense, a conference about people and for people.

I had been looking forward to Nashville for many months.  The only minor obstacle raising my stress levels was the flight itself.  I have a well documented discomfort of flying and this would be my first transatlantic flight by myself.

To make the flight better I had booked a window seat – ironically I do better when I can see the horizon or the ground below. However I’d manage to book the only seat on the plane without a window. What the……?!?!?!?!

I tried to explain to the cabin crew but as the flight was fully booked I had no choice but to go back to my seat, albeit with another glass of Prosecco as an apology.

The lady next to me however had a much bigger problem – her TV wasn’t working.  It was at that moment I felt the universe had conspired towards us.  We started talking instead.  It turned out to be one of the best journeys.  Joyce was turning 70 this year and was making the trip home to South Carolina having visited family in England.  We talked pretty much non stop the whole way.  So much so that another lady came over to join us – she heard the ‘animated’ discussion and wanted to join in.  In that 8 hour flight I entered the worlds of two other people. We shared stories, opinions and wine.

Although I didn’t know it at the time it was to set the tone for my whole trip.

After a 7am start on the Sunday I figured I could justifiably spend the afternoon doing a tour of Nashville.  To be specific is was a 3.5 hour extravaganza of ‘Nashville the TV show’. It was as amazing!  Not only did we go to all the sites they film at but we took in the surrounding area including people’s houses (Taylor Swift, Dolly Parton, Tim McGraw etc) plus we got to go inside the Ryman Auditorium. Hugely exciting!  The people on the tour were as friendly and entertaining as our tour guide. Apparently my Scottish accent was ‘awesome’ although by their own admission their impersonations of it were less so… 😀


At dinner that night an older lady clambered up on to a bar stool next to me.  Fearing she’d break her hip I offered to help. I was emphatically told ‘I can manage just fine but thank you all the same’.

We got to talking – she’d also been at a family wedding over the weekend but was now intent on ‘partying’ in Nashville.  She was 73.  She went on to tell me that she was from Colorado. A state, which she proudly explained, has one of the longest life expectancy.  Seemingly the thin air makes your body work that bit harder especially with all the ‘outdoor living’ The whole conversation was a testament to positive ageing. Her only gripe was the arthritis limiting her skiing now.

The next 2 days would be jam packed with delirium research, raising awareness and education.  The aspiration being to better understand something so complex and yet so simple in terms of its basic management.

As I got on the plane to come home I thought about how fortunate I’d been to meet so many incredible people. Each of them allowed me to enter their world for a short period of time and by doing so they have changed mine forever…..

geriatrics, nhs

Free, free, set them free


This week I’m in Nashville for the American Delirium Association Conference (#ADS2017).  Day one was heavy on education and although I was familiar with most of the content I always find it interesting to hear how others interpret and explain things. One session on delirium in the Intensive Care got me thinking:

Screen Shot 2017-06-04 at 19.30.04

Now when you mention restraints to people in healthcare they will generally think about the kind that have people strapped to a chair or cot side.  Thankfully these types of restraints are no longer routinely used in the NHS.

There are some kinds of restraint that can be a good thing for example, the plaster cast that stops a fracture becoming displaced.

However what about the restraints we use by proxy?

As I sat in the lecture I got to thinking about what happens to a person when they are in hospital.  Last week I talked about the role of the environment in particular how it can be damaging to the person with delirium or dementia.  By making simple changes there is evidence that the person will get better more quickly, so of course the environment was number one on my list.

The #endpjparalysis campaign on social media also highlights it.  I recently had a patient comment she would like to get dressed but unfortunately her family had only packed her a nightdress. Most equate a hospital admission with serious illness however the aim is to get the person better as quickly as possible so we do need to see beyond that.  One could argue that a person’s dignity is restrained by having them rehabilitate (walk, eat etc) only in nightwear.

Which brings me on to 7 day access to a multi disciplinary team (MDT).  We know that early access to physio and occupational therapy can have huge benefits not only on the physical but also cognitive health of a person.  Could limited access to the MDT be a restraint by proxy?  I’m not so sure.  I do think they are spread far too thin.  I also think that some of the tasks could be done by others, in particular, our healthcare assistants.  I just wonder if they perhaps need to be more empowered to do so instead of just doing unto the patient….?

One thing that does not help in the early mobilisation of a person is the use of sedation.  It’s not just an issue for ITU, many of our older people are on medications that actively sedate them e.g. the ‘little sleeping tablet at night’, strong painkillers even some antihistamines.  I would argue that Geriatricians in conjunction with our pharmacy colleagues are good at trying to rationalise medications.  The community, especially care homes are not quite as good.

So coming back to the hospital setting both in acute and rehab here are a few other things that could be considered restraint by proxy;

  • urinary catheters
  • hearing aids that don’t work or are not fitted
  • no glasses
  • buzzers that are out of reach
  • empty water jugs and cups
  • inappropriate walking aids
  • no walking aids
  • no ‘getting to know me’ or ‘what matters to me’ discussions

Most would be horrified at the idea of going back to the use of physical restraints but I wonder if we realise all the other ways we achieve the same effect? Perhaps we ought to reframe the discussion so that as with straps, belts etc other restraints by proxy can become a thing of the past….