health, nhs, Uncategorized

Lovely day

It’s that time of year again – changeover week. This changeover, more than others, is a particularly busy time.  It’s when our new FY1’s start.  No longer are they on the wards or in libraries learning the theory. Now it’s time to put it into practice.

It’s both terrifying and exciting!

This year I was again involved in the ‘Preparation for Practice’ course that our Resuscitation team and Simulation Centre organise.  The day takes our new doctors through an array of simulated scenarios using Forth Valley specific paperwork and protocols.

The team involved is huge and varied reflecting the breadth of the expertise involved in caring for our patients and keeping them safe.  What I particularly liked was the involvement of our current FY1’s.  They were brilliant in offering practical tips but more importantly reassurance that it will all be fine. It was also lovely to see how far they’d come since taking part in the same program the year before.

For some though the reality of it all became a bit much. The day came at the end of a long week of induction and shadowing. The scenarios are specifically designed to be as realistic as possible but with an emphasis on a safe learning environment.  However no matter how much you tell yourself the ‘patient’ bears a striking resemblance to your FY1 shadow buddy the situation is real.

There was a dawning realisation that patients don’t behave like they do in textbooks.  They don’t tell you what’s wrong straight away.  You have to work it out based on the clinical exam. You have to have the confidence that you are hearing crackles in the chest and not just the rustle of the sheets on the bed. Then there’s the tests.  Why do they not come back straight away?  Of course that’s assuming you can get bloods off them – some don’t have great veins or are so confused they wont let you near them.

However there’s a sigh of relief when it becomes clear what’s wrong. A plan can be made and treatment started.

In my scenario however our patient didn’t respond to treatment and began to deteriorate.  In real life that happens and it is stressful.  As a doctor (or a nurse) to try your absolute best and see it not working is the worst feeling.  The time that you were willing to speed up to get the person better you now wish would slow down to give you more time to fix them.

One of the objectives of our scenario was how to have those difficult conversations when things are clearly not getting better.  My role was to demonstrate a positive discussion about a treatment escalation plan. Any conversation that involves resuscitation has to handled with great care and sensitivity but always with the intention of doing the right thing by your patient.

After the scenario had finished we had 15mins to debrief and discuss what had just happened.  Pretty much everyone thought they had done terrible.  Of course this wasn’t true but that’s what this particular stress does to doctors and nurses.

In real life what also tends to happen (especially out of hours) is they will be asked to immediately go straight into another high stress situation.  There is precious little time to write up notes never mind reflect on what went well and check everyone, including yourself, is ok.

This kind of chronic stress was something that was never really talked about or acknowledged when I first qualified.  Some twenty years on and induction programs now include sessions on well being and stress management.

As I was writing this Bill Wither’s song came on the radio with the lyrics:

‘When the day that lies ahead of me
Seems impossible to face
When someone else instead of me
Always seems to know the way’

I took this as a sign!

So as our new doctors take to the wards I can’t make the patients behave in a more predictable fashion.  Nor can I take away the feeling of nausea.  I can however ask how it’s going and buy the coffee. So to that end I know it’s going to be – a lovely day…..


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…..

Dementia, education, Uncategorized

All that matters to me


This week I was invited to talk to care home staff at Erskine.  It was part of a series of talks to raise awareness about delirium, mobility issues in those with cognitive problems and dementia.  In addition to these clinical talks were two from a relative and carer perspective.  One was Tommy Whitelaw (@tommyNTour) talking about his mum Joan.  The other was given by a family member of a current resident.

I must say when I saw that relatives were speaking I thought: ‘Wow! That’s quite a brave thing to do.  I wonder how the staff will react?’

I’m all for putting my head above the parapet but not many others are.  It can be incredibly difficult to hear feedback, no matter how constructive, without first putting it through a defensive filter.

That said I found what they had to say both incredibly moving and challenging. I don’t mean that critically either.  When you work in your own tiny eco system of healthcare you can desensitise or even forgot how a simple turn of phrase can inadvertently upset a person. To hear that your mum is ‘too good’ for a care home after you’ve spent months anguishing over the decision can bring back feelings of guilt.

We were also reminded to take the time to remember that this person is a mum, a dad, a brother, or a sister.  This person will never be a resident or a client to a family.  They are people with stories and lives of their own.

It was these talks that had the greatest impact for me.

You see we talk a lot about being person centred but if feels like being in an echo chamber at times.  What do I mean by that?  Well, it tends to be people working in the health service talking about the need to be person centred.  I rarely hear the patient or relative perspective in these meetings.  It’s also started to feel a little competitive:

‘And the prize for person who talks the most about person centredness goes to…..’

I personally feel that it you were you wouldn’t feel the need to go on about it so much. You would just be.

So what makes the difference then?  Tommy and I spoke about some of the people he’s met over the past few years.  It’s quite a list although I got the impression that those who have affected him the most are those on the ground, so to speak.  For all the pledges and promises of funding from on high it seems to get stuck on the way down to those who need it most.

As Tommy said caring is not seen as a career to aspire to. Even those working in the care home sector will struggle to get access to adequate training and education.

We have created this culture so we alone are responsible for changing it. I don’t want to hear people talking about what they should do.  I want to see them actually doing something!

I’ve always been a believer in the concept of small steps of change. You are however investing time and effort in a very distant future so it does require patience.

Looking around the room after Tommy spoke and seeing many in tears, it was clear that a difference had been made.  And that’s all that matters……

Leadership, nhs, Uncategorized

Everything is awesome

I have always considered myself a positive and naturally optimistic person but several events this week sought to test that.  To be fair some were truly awful. However there were some things that, in my opinion, restored an equilibrium.

The first was the news story about mental health as championed by William, Harry and Kate:

I quite liked the honesty with which they talked about the British ‘stiff upper lip’ culture. This is such a ridiculous notion when faced with the tragedy of losing your mum at such a young age.  There is no silver lining or looking on the bright side.  It’s just bloody awful and should be treated as such.  That said I do think how they have channelled it into something good is remarkable.

They are not the only people who are able to do such things.  Look around and you’ll see people from all walks of life trying to create something good from terrible circumstances. It could be running a marathon for charity or volunteering.

There are parallels with our daily NHS life.  Recently I helped one of my trainees complete a near miss incident form. There was no harm and the patient and family were informed. The main thing from my perspective was to identify exactly what went wrong and more importantly how to make sure it doesn’t happen again.

The process of documenting failure is, by its nature, long, depressing and overwhelming negative.  There is no way to make it a positive experience for anyone. What you have to do though is pick everyone up and somehow turn it around. It’s a difficult one to balance as you want people to feel empowered to make a change but equally you’re trying not to diminish the mistake in the first place.

I believe we managed to achieve this balance.  A plan was made and over the next few weeks I am optimistic we will have something in place that ensures this particular incident will not be repeated.

Which then brought me to this quote that I saw the following day on my twitter feed (thank you @johnwalsh88): C91f2UvW0AAZKbu.jpg-large

This to me is much more reflective of who I am nowadays. I think it’s what we should all be to be honest. So with the glass half full I would argue that for every situation you hope for the best but plan for the worst.  To me that is about having plan A, B, C, D etc etc

This philosophy is reflected in a postcard I have on my wall at work that says ‘Failure is not an option’  It’s from the Apollo 13 mission. It makes me smile every time.  Now you may think I am deluded or living in denial but I agree with the statement. Failure is not an option.  You just haven’t found the option that works.  It is true of the NHS and in life that you will need to try out many different options until you find the one that works.

So on that note I go into another week with my eyes wide open, optimistic that it will be a good one. If it’s not, well, that’s just a chance to try out Plan B…




Leadership, nhs, Uncategorized

Enjoy the Silence


I’m on holiday. Hallelujah!

When I eventually got home on Friday night I felt like I had literally crawled over the finish line and collapsed in a heap.

Cross covering colleagues immediately increases your workload however there is an understanding and clarity of what is expected during this time. My job is to keep our patients safe and lead the team.  I become much more directive Dr Copeland in order to manage my time to its maximum efficiency. This is especially important given I work 3 days. I also expect the team to know their role.  What is crucial is that we check in with each other just to make sure.

This clarification of understanding and expectation is something I do whenever I meet a new patient too. If you don’t and instead assume you will get something wrong.  I’m not talking about clinical mistakes where patient harm occurs. What I mean is the type of mental harm that comes from not explaining things properly or giving opportunities to ask questions.  Most importantly it is about setting expectations e.g. when a test will happen or when you might get home.

It also applies to non clinical situations.  This week I had the joy of manning the middle grade rota for the first time.  When I say manning, fire fighting is probably a more accurate term.  Without getting into detail, there have been issues.  I’ve done rota management in all of my jobs so this one didn’t particularly phase me. Yes, it’s complicated with all the rules around rest days, number of hours worked, days in a row, etc etc but not overly so.  What was surprising to me was the virtual tsunami of emails that came after it was distributed. No one was happy.

After a while a pattern emerged. It seemed to me what was missing was this fundamental clarification of understanding and expectation.  The specifics of promised swaps and annual/study leave requests while obviously important did not seem to be as important as acknowledgement of the request and when to expect a definitive answer.

I have come to hate the ‘death by email silence’ that occurs in the NHS.  In that vacuum a person can create all kinds of scenarios that may (or more likely) may not be happening in response to sending an email.  These assumptions can lead to all kinds of behaviours.  In a rota situation some may take that silence to mean ‘yes, have that week off’. Or it can have the opposite effect so the person can’t get to a family wedding, for example. Either way it leads to both an unhappy workforce and rota management team.  In my experience a simple ‘your email has been acknowledged. We hope to have an answer for you by X date’ can go a long way to defusing a volatile situation.

So as I put my out of office on there is an understanding that I will not be checking my emails.  My annual leave week is a time to relax in the company of family and friends.  The expectation is that when I get back to work I will be refreshed and ready to go again…

education, Uncategorized

Learning to fly…

Loch Lomond

After 18 months of hard work the first paper I’ve ever properly written up was finally submitted.  It wasn’t a solo effort by any stretch of the imagination.  I was lucky enough to work with James Fisher and Andy Teodorczuk in putting it together.

I’m also under no illusion that it has a long way to go yet and may not even be published at the end of the day. However the sense of achievement once I clicked submit was amazing!

That said it was a project that pushed me well out of my comfort zone.  I’ve always liked the idea of being involved in academic medicine but thought I wasn’t really a good fit for it.  I have many preconceptions about my academic colleagues. For one they are very smart.  They make it look easy.  Also they must be very patient people given how long  research projects can take to bring to fruition.

It also seemed I was making similar assumptions about myself – I get bored easily. I like detail but only so much. I have no patience.

Here’s the thing though, while my own personal attributes may be based on the gazzilion psycho-analysis questionnaires I’ve done over the years, they are by no means set in stone.

Over this past year or so I have become much more patient. No really, I have! I still have a low boredom threshold but it’s definitely higher than it used to be. However the ability to spend literally hours on detail is something that I have come to enjoy.  I’m not sure it’s fair to say my brain has slowed down but it definitely has an ability to concentrate for longer.

I think I may’ve managed to modify some of my fundamental personality traits.

Now you could argue that will happen when you are doing something you care passionately about.  I’m not so sure.  I have seen people work in the same way, doing the same thing their whole lives and I don’t remember seeing any fundamental change happen to them. I’m not even convinced they were all that happy either but that’s just my opinion…

I think you need to slightly step out of your comfort zone.  It could be that you work in the same speciality but perhaps try a different facet of it like I have with the delirium education work.

Or you could be like some of my colleagues who have moved their work environment to say the community or ED.  Some are changing hospitals but staying within the same Health Board. I also know colleagues who have taken up work with the Scottish Ombudsman, GMC and the Scottish Government.

I’m pretty sure if you asked them 20 or even 10 years ago what they would be doing in the future, it wouldn’t be what they are now.

This idea of a mobile workforce has been around for a few years now.  However how doctors define their working career is beginning to evolve.  The challenge for organisations is how to adapt to this.

Perhaps we all need to challenge preconceived notions of ourselves from time to time. Try something new or just a teeny bit different from the norm.  Who knows what you might be capable of…..


World delirium day 2017….


Straight off a weekend of on call I went into prep mode for World Delirium Day (Wednesday 15th March). The idea of doing a day of global awareness had been talked about for a while but only in the past month or so had it really become a reality. We at the Scottish Delirium Association were keen to be involved.

We’d done a similar social media campaign for one of our meetings in June 2016.  Myself, Ajay Macharouthu, Alasdair MacLullich and Karen Goudie began a week of tweeting and FB posting which culminated in the live broadcast of the SDA conference via Periscope.  I think we were all a bit bordering on delirium ourselves by the end of it. However anything to raise awareness in delirium can only be good thing.

The hub of World Delirium was Using #WDD2017 social media was again used as the driver to advertise and influence. During my weekend on call when I wasn’t seeing patients, I was loading up tweets and FB posts, writing a piece for our Comms department, ordering up more resources to share (thank you lovely OPAC!) and generally trying to do my bit.

Ironically on the day itself I was focused on another aspect of brain dysfunction.  We’d had a stroke simulation day in the diary for months and wasn’t one I was about to cancel.  Instead everyone got a delirium lanyard and a reminder about what else the brain does.

As the day went on my phone was constantly lighting up either with SDA tweets and FB posts as well as my own twitter feed.  My multi tasking brain was kept active until well into the night.

Similar to last year I did have a sense that we need to be moving on from merely raising awareness.  We need something more tangible to show for it.  This has also been the view of some of my delirium education colleagues.  On the back of this we have been developing a sister website to iDelirium to focus purely on education.  The was launched to provide information for both healthcare providers as well as patients, families and carers.  More importantly it is a one stop shop to share educational tools such as slide shares, simulation, videos as well as updating on the latest research and delirium meetings.  It’s still under construction but we’re all pretty excited to be able to provide resources to those who are looking to not only learn but educate others about delirium.

We have also submitted an application to develop a MOOCS (Massive open online course) which, if approved, will be the first of its kind in delirium education.

And finally the undergraduate work that myself, James Fisher and Andy Teodorczuk have been writing for the past year looks close to fruition. As does the undergraduate nursing education work.

Events like #WDD2017 are fantastic to raise awareness but I have a sense that people want more.  People are no longer content knowing what it is, they want the skills to know how manage it. We need more research to help us better understand delirium so we can develop new management strategies and education tools.

Like a lot of conditions in medicine while we may not be able to entirely eradicate it we will have the power to control it and that’s a pretty worthy aspiration of any delirium superhero…..



nhs, Uncategorized

It’s all about you….


I’ve just finished another weekend on call.  They are increasingly a test of endurance.  I always feel not just physically tired but mentally drained after it. Perversely though I’ve always quite liked the acute receiving aspect of my job.  When you speak to medics they will say that it’s not the work they don’t like but the intensity of it.

It’s this intensity that has lead me to reflect on some people’s behaviours and attitudes when on call, myself included.

This weekend was not as busy as some have been lately. That said there was the odd surge in demand. During one of these our Emergency Department began to struggle as they were short staffed.  The solution?  Pull one of our middle graders through to help cover until their shift change and staffing numbers would be restored.  Sensible? Yes, very.  We were managing just fine.

However this was not greeted with universal agreement or understanding. There was a huge sense of injustice about it ‘no one helps us when we’re short!’ This carried on into handover with mixed responses from the rest of the team.

It settled quickly and life went on as before.  I did debate at the time whether to get involved in the discussion but I didn’t.  In part I was mid writing up my own notes and also being tired I had a sense I may be somewhat clunky in my feedback.  I may have been thinking:

’Quit moaning, think about the patients, it’s not all about you, so can it!’

However there was a danger that with my feedback filter turned off I would actually say just that so I stayed mute.

Also I’ve been there myself.  I understood where this person was coming from.  As a middle grader I was, at times, the biggest pain in the arse when on call.  I couldn’t see further than my own nose never mind thinking about my colleagues.  I did however put the patient at the centre of my various rants.  I also thought for a long time this would make me beyond reproach when it came to the effect I had on others.

While I accept the patient’s needs are paramount I would strongly argue do not forget about your colleagues.  This point was reinforced with a stroke thrombolysis situation I had recently.  The phone rang at 4.35pm just as I was starting a mountain of paperwork.  I wasn’t on call that night so was hoping to get away on time.  I was told there was a person in the emergency department who was FAST positive. Realising that I was going to be at least another couple of hours I actively sighed down the phone at my colleague. I was also about to start moaning when I decided to button it and go downstairs. My ED colleague was also a little fed up.  They’d had to come in on a non clinical day to cover staff absence.  All our issues were put to one side however as we focused on dealing with the person who was having an acute stroke.

The treatment went very well and the family were delighted.  It was at this point I felt I could leave.  I thanked everyone in the room and went to chat to my colleague.  We chatted about each others pressures and frustrations long enough to feel equilibrium had been restored.

At times all I hear is staff saying ‘what matters to me’ but not asking their colleagues ‘what matters to you?’  We need to realise that its likely to produce the same response.  Be person centred but not to the extent that it’s all about you….

nhs, Uncategorized

I like to move it, move it



A phrase I often use in the TIA clinic is ‘you’re getting an MOT of sorts’.  What I mean by this is I’ll take a history, carry out an examination, check some bloods, do a few scans and get an ECG. It’s a pretty comprehensive assessment.  People seem to like that turn of phrase – it’s familiar and it’s reassuring.

With this in mind I decided it was probably about time I carried out a similar type of MOT on myself. Like medicine you need to know what specialty to refer to.  To my mind life MOTs fall into 6 main areas:

  • health
  • fitness
  • financial
  • legal (POA, wills etc)
  • spiritual
  • relationships

I’d pretty much done the health MOT to death in recent years so figured I could skip that.  Other areas are also in good shape so I turned my attention to fitness.

Since changing jobs a year or so ago I now get loads of fresh air and exercise thanks to all the walking I do in my commute.  However my favourite thing to do is swimming.  The problem is that my local pools are all quite far away and usually shut on weekends for lessons.  So I joined a  gym. Well, technically I joined a swimming pool I suppose.

Included in my gym membership was the opportunity to undergo a fitness MOT.  Being in the proactive/worried well section of the population I signed up immediately.  My first assessment was last week. As excited as I was to know what my VO2Max was (?!?) I just  wanted to know I was generally in ok shape.  Turns out I am. Hooray!  However my celebratory mood was cut short when the assessor said ‘aye but you doctors never stick at it’ This mildly irritated me although I wasn’t entirely sure why.  My response at the time was to point out that the gym is intensely boring and I’ve no idea why anyone would want to ‘stick at that either’.  I felt I had the moral high ground with that…

For me exercise has never been about the fitness side of things – I use it as stress relief and relaxation.  If I get fit, so to speak, it’s purely by accident.  I know many medics who view exercise as something else to be wildly competitive at.  There are others who periodically train for something e.g. a triathlon or 10K and then not go back to it.  For the rest it’s simply that they do not have the time or the energy to do anything other than pour a glass of wine or flop into bed.  I would argue that it’s this type of fatigue that can lead to feelings of guilt which in turn can make stress levels worse.

One thing I would like to do is suggest medical staff wear pedometers. To start with I think it would surprise many to see just how far they walk in a day.  During an average on call  I can walk 4 – 5 miles yet somehow it’s not perceived as exercise. My legs would argue otherwise!

So while I entirely support initiatives to improve the health of NHS workers I do think we need to better recognise covert exercise. The type that many do everyday but don’t realise. With this in mind I’m going to get my colleagues some pedometers to see who is the most traveled within the realms of FVRH. I suspect the notion that we doctors don’t stick to any kind of exercise program is a misnomer.  It’s just our gyms are the corridors of the hospital…