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Le Freak

June 26, 2017 clcopeland

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……

geriatrics, nhs

Free, free, set them free

June 5, 2017 clcopeland

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:

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….

Dementia

Is this the world we created….?

May 29, 2017 clcopeland

I’ve been asked to talk at a Masterclass on Design for Dementia and Ageing at Stirling University this week. The brief is 10mins on the environment, dementia and acute care. The focus is on the real world aspect rather than reams of data.

So what do we mean by the environment? Type that into Google and you get this:

’the surroundings or conditions in which a person, animal, plant lives or operates’

They often like to provide an example of how to use the word and given the subject matter this one really struck a cord:

‘survival in an often hostile environment’

That is exactly what coming into hospital is like for the person with dementia.

Now before I get into this some more I want to be clear from the start that the people working in hospitals do not deliberately create this nor do we go out our way to make it as horrible an experience as possible. That said you will frequently hear colleagues talk about how hospitals ‘break people’. Even in my recent visits to care homes staff would tell me about how residents would seem both cognitively and physically worse after an admission to hospital.

We know that people admitted to hospital are not there because of their dementia but due to conditions associated with it e.g. falls, hip fractures, chest infections, delirium etc. With that in mind hospitals are perfectly designed to deal with this array of illness. What it was never designed to do was be a place that met the needs of a cognitively impaired person.

Years ago I heard a talk that somewhat poured scorn on the notion of ‘artificial’ dementia friendly environments. At the time I could understand the frustration – how does a mock 1950s kitchen or living room help? If they’re well enough to be in a sensory garden should they not be at home recuperating/rehabbing….?

However people with dementia get sick just like everyone else. So when you need admitted with pneumonia or a fracture then I do think hospitals should do more. It is not the person’s responsibility to adapt to our broken systems and processes.

There is evidence that if we invest in the environment we can reduce length of stay, falls and violent/aggressive behaviours. Not to mention the positive effect it can have on staff caring for these people.

The evidence points towards simple, inexpensive measures having a big impact. Clear signage, quiet, well lit clinical areas. Ironically the move toward single rooms in new build hospitals has prompted discussion about resurrecting the Day Room as a place for social interaction.

Perhaps one of the biggest challenges is in creating an environment where families/carers are welcomed. If we are striving to have the person with dementia feel safe and secure then we need them. They very often point out things that we have become blind to ourselves.

So I would like to see the hostile environment of acute care become a place where the person with dementia thrives and not merely survives….

For more info:

https://www.kingsfund.org.uk/projects/enhancing-healing-environment/ehe-design-dementia

http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4075017/19870707-ace6-4c5c-b3df-0556816f61fe.pdf

http://futurehospital.rcpjournal.org/content/2/1/63.full.pdf

http://dementia.stir.ac.uk/design/virtual-environments/virtual-hospital

Thanks to Janice McAllister (@janicemcalister) for providing some of the referneces

geriatrics

True Colours

May 22, 2017May 23, 2017 clcopeland

Our lunchtime meeting this week featured a talk by George (@ilovehermind), one of our junior doctors on health issues in older LGBT people. It was incredibly thought provoking. It’s rare that a presentation makes me want to immediately go and learn more. However as I soon discovered there was very little to find.

First up I went to the British Geriatrics Society website and typed ‘LGBT’ into the search facility. No results. Hmmmm…. disappointing. I then tried typing ‘Gay’ – nothing again. In fact despite typing an array of acronyms and looking amongst the various headings I couldn’t find anything.

I tried Health Improvement Scotland. They’re bound to have something I thought. Eh, that’s a no too.

I was starting to get annoyed….

Eventually I was able to find the articles that George had referenced in her talk. What I hadn’t really appreciated until now was the range of issues that our older LGBT community faces. More over how little attention or recognition they receive.

I am also slightly ashamed to say the issues raised had never really crossed my mind. I guess I have always considered myself to be the type of person who doesn’t pay all that much attention to perceived differences. I will treat people the same whoever they are.

That said over the next couple of days I began to reflect on my own practice. To my knowledge I have looked after only a few older LGBT people. I have never asked nor have I made assumptions.

Is this wrong?

I’m beginning to wonder if it is.

I have been corrected on many occasions by the women who I have said hello to as ‘Mrs’ only to be told ‘it’s Miss’.

Then there was the man who I looked after years ago with the low impact hip fracture. He told us some weeks later that in fact he had been born female but had been brought up and identified as being male. This was told to us in confidence and I’m very honoured that he felt he could share that. However when a well intentioned Healthcare Assistant shaved the beard he had been trying to grow for months the devastation felt by all was awful. He never said not to and she just assumed he would want to look well groomed. Now I appreciate that’s a very specific story but it has stayed with me. What could we have done differently? Each time I come up blank…. The story came back to mind when I read this quote:

‘Coming out’ is an on-going, dynamic process. Every unfamiliar person and place (such as a hospital or nursing home) demands yet another decision about disclosure. (Age UK)

So as we talk about frailty and all the other conditions that occur in old age I don’t recall any conversation about the needs of the LGBT community in old age.

Are they any different? In some respects yes but in ways I hadn’t really considered before. There is a higher proportion who drink alcohol and/or take drugs. We are also now seeing approximately a third of newly diagnosed HIV cases in the over 50yrs and 5% are >65yrs.

However what I hadn’t appreciated was the issue around social care and loneliness. The combination of family estrangement and/or no children leading to social isolation and lack of support network. Some good news and an attempt to address this lies in Manchester City Council opening the first LGBT care home:

https://www.theguardian.com/world/2017/feb/21/manchester-city-council-to-create-uks-first-lgbt-retirement-home

To be honest George’s talk was a real eye opener for me. I became a Geriatrician because I believed that older people were largely the forgotten mass who got a rubbish deal from the NHS. I wanted to be their advocate. I now realise that I have been somewhat blind to a group of people within this. I am delighted that Geriatrics is now front and centre in the NHS. However I feel we may have some way to go to ensure that all older people receive the care they deserve and are entitled to.

For more info:

http://www.stonewallscotland.org.uk/sites/default/files/LGB_people_in_Later_Life__2011_.pdf

http://www.tht.org.uk/our-charity/Facts-and-statistics-about-HIV/HIV-in-the-UK

http://www.ageuk.org.uk/health-wellbeing/relationships-and-family/lgbt-information-and-advice/lesbian-gay-bisexual-or-transgender-in-later-life/

http://www.ageuklondonblog.org.uk/2017/05/19/dementia-care-lgbt-community/?utm_content=buffer57b6c&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

health, Leadership

Run the World (Girls)

May 15, 2017May 16, 2017 clcopeland

This week was the Centenary of the Medical Women’s Federation. Although I couldn’t get to events down in London Izzy Utting, an Edinburgh medical student, had organised an event entitled ‘How to have your cake and eat it….’ With actual cake!

I was asked to speak partly due to my role in the MWF (secretary Scottish Standing Committee) but also as someone who has apparently achieved some degree of success as a female doctor.

This I had to smile at that. ‘Me? You sure about that?’

Preparing for my presentation I couldn’t feel any less inspirational or motivational. I did seriously debate putting a slide up with:

‘You’ll figure it out’ (drops mic and walks off stage)

Ahead of me were two amazing women Dr Sarah Stock (@evbasedbaby) and Dr Rebecca Heller or Bex (@rebeccalily) talking about their career. While there were stories of inspirational high achieving women they were both refreshingly honest about some of their life choices and career failures.

Although our talks were prepared independent of each other there was a recurrent theme – Imposter Syndrome. That nagging irritating voice in your head that tells you are a fraud. The one that causes everyday to be spent in state of anxiety worrying you’ll be exposed as a charlatan. I must say I hadn’t actually come across this term until relatively recently but I had experienced all the symptoms.

You see Imposter Syndrome is like a parasite – feeding off your insecurities and self doubt. It messes with your head so that you are unable to recognise other women going through the same thing. And let me tell you they are. It’s just it makes you believe that the first rule of Imposter Syndrome is: You don’t talk about Imposter Syndrome.

Bex shared the statistic from an internal report for Hwelett-Packard that men apply for a job when they are 60% ready compared to women who wait until they are 100% ready (Sheryl Sandberg, Lean In). I think this probably tells us all we need to know about its destructive power. I’m also pretty sure this is why only 24% of Medical Directors are women too (Kings Fund).

So I decided to face mine head on. A parasite only survives if you feed it. Or in the words of Maya Angelou:

So I stood up and talked about how I had failed. Quite hard to do as a control loving, micro managing perfectionist. That said I made it sound as spectacular as possible – old habits…..

I also talked about what I was lead to believe were terrible career choices. For example starting a family as a Registrar – something only a handful of people did at the time. I was also told not to go part time because ‘you’ll never get a Consultant post’. And for goodness sake what was I thinking about going part time again as a Consultant. Apparently you’re meant to increase your work load at this point. Life it seems can wait until you retire.

This is simply not good enough.

So what did I tell these young women:

‘You do what’s right for you at the time’

That means:

You will make mistakes – it’s ok you will learn stuff from this
You have the right to change your mind
Trust your instincts – especially when taking advice. That person may only have their own interests at heart, not yours.

So can have your cake and eat it? Yes. Absolutely. And I encourage you to try every single one….

nhs

Go with the flow

May 8, 2017May 23, 2017 clcopeland

Monday morning, post weekend on call. It’s not been the best in terms of bed capacity and ‘flow’ but we’re all still here. Good enough? Well possibly not. As I started my ward round I was paid a visit to tell me we were minus many many beds. ‘Was I aware of that? It’s simply terrible. Please do whatever you can to make more beds become available’

‘No problem’ I replied.

There isn’t any point getting annoyed. It’s not the first time I’ve been interrupted simply to tell me how busy it is. I’ve even been summoned to meetings to tell me in person. After a fashion you tune out the white noise.

However I have had trainees and nursing staff remark to me;

‘What difference is sending one person home when we are minus 50+ beds?’

‘What I hear is I’m not working hard enough. What about the times when everything is going well? You don’t get pulled into a meeting to be told good job’

‘Do they think I’m sat on my arse twiddling my thumbs?’

So reflecting back on the weekend, it had all started so well. The sun was shining and we had beds.

There was nothing especially remarkable about the case mix or the volume coming in. This continued on into Saturday but by lunchtime it became apparent there was a problem. No one was moving out of the acute assessment unit. By teatime things were stuck.

It was clear that we were experiencing a severe case of constipation. Every attempt to discharge precipitating colicky pain in the system. It was just too hard. By Sunday we had some flow but not the good kind. It was the kind of overflow flow that goes into all the wrong places.

So how do you manage a bowel impaction secondary to constipation? Well sometimes you need to decompress the situation through a naso gastric tube. It doesn’t clear the blockage but it does make you feel better and able to cope with the pain.

So how do we achieve this in the NHS? Well, we don’t really. We just remind people how uncomfortable they are and imply it’s their own fault as they aren’t trying hard enough to move things along.

I think we should instead allow people to ‘decompress’ naturally. I’m talking about listening and acknowledging how hard it is. Allow people to vent. Once rid of all that hot air and bile you might find people are much more willing to offer practical help and suggestions.

Now that of course still leaves the constipation blocking the natural flow of things. I would recommend a variety of laxatives for this.

There’s the gut stimulant – perhaps the multi disciplinary team (MDT) in this situation. Get more physio and occupational therapists. Or perhaps offer a targeted and focused MDT to get people up, help them with their walking, offer adaptations and support at home.

We have the stool softener – making the journey out that bit more pleasant. Our ward teams including pharmacy are key here. Taking the time to explain to the person and their families what has happened and what to expect on discharge. All of this neatly packaged into an immediate discharge letter and sent to their GP.

You also need to tackle things from the other end through a high phosphate enema. To me that’s social work. Get the assessments done, secure funding and either get the person home with the care package or into a care home as quickly as possible. You will get an almost immediate result with this.

Employ all these strategies, flow returns, pressure is relieved and everything is that much better. Ah…..

Of course as many of my older patients tell me, it’s best not to get constipated in the first place. I am constantly being told that prunes are the answer. They are tasty, effective and cheap. I guess that’s what integrated health and social care aspires to be (just not as cheap).

So will tomorrow be any better? Marginally. Will I do anything different to what I already do? No. Sometimes it’s best to just go with the flow…..

nhs, Uncategorized

Everybody’s Talking (at me…)

November 28, 2016May 28, 2017 clcopeland

I’m stuck. How to I get people to assess and document mental capacity?

This is something I have been struggling with for a few years now. I know I’m not alone either.

In last weeks blog I alluded to the fact that part of the Older People in Acute Care inspection focused on mental capacity documentation. I also spoke about how nursing staff were being held to account for it when it is medical staff who are responsible.

I also came across this tweet by the British Geriatrics Society (@GeriSoc):

‘Some pts in hospital for ages, have multiple procedures, before capacity finally questioned only because they want to go home! #bgsconf‘

This is a situation I have been witness to repeatedly.

How can we be striving for person centred care and yet the most fundamental aspect of this is not addressed?

It was therefore fortuitous that I was asked to present to our Clinical Governance Board on this topic. So with the question twirling in my brain of how to improve it I started with some basic education.

pasted-image — Does this person have capacity? What about the others….?

Now the first thing I had to do was make an assumption that the people sat in the room had capacity. That’s how we should approach the assessment of anyone we see in hospital, clinic or at home. They should have a broad understanding of what is wrong with them, the treatment offered and what would happen if they refused treatment. They also have to be able to communicate this decision and we should help facilitate this if they are unable.

I quickly ascertained that my audience was full of mentally competent people who were keen to hear what I had to say.

I moved onto what is meant by mental capacity.

Just because you can make bad choices it does not mean you lack mental capacity. You just have to explore the reasoning behind why they believe what they do.

Mental capacity can also be fluid. This is true in the case of the person with delirium. As the condition fluctuates there can be times when the person is lucid but at other times they can be confused and/or hallucinating.

Finally mental capacity is task specific. This is of particular importance in the person with dementia. They may be able to understand the need for treatment for a chest infection but lack insight regards their own safety at home.

So how can we maximise the decision making ability of the person? Well first you have to have enough time to go through things, including time to re-assess where necessary. You need peace and quiet. The person should have every possible chance to use what capacity they do have. That means put their glasses on, check that hearing aids work, have written information available and allow family members or carers to be present.

Lastly I have spoken about mental capacity in relation to medical treatment. There is a whole other aspect to it that encompasses decisions pertaining to financial and welfare matters.

With all this to consider is it any wonder that mental capacity is a complex and time consuming process?

So back to my question – how to engage people with it? I personally think we need a much broader range of people trained in the assessment of mental capacity. I think our nursing staff have much to offer in this area and I would welcome any thoughts or comments around this.

I also think we need to ensure that medical staff are properly educated. It is a daunting topic but one that is relatively straight forward to understand if taught well.

Meantime I draw parallels with DNACPR discussions and documentation in terms of importance and the legal aspect. We would not dream of having a conversation around treatment escalation/resuscitation and not document it. Why do we not apply the same level of importance to a person’s mental capacity?

It makes no sense….!

nhs, Uncategorized

Doing the best you can…

August 29, 2016May 28, 2017 clcopeland

I’ve been reading Brene Browns book ‘Rising Strong’ in which she explores this idea. I’m not entirely sure why but for the first time it actually hit home. I’ve heard it said a hundred times but generally dismissed it. complaints_328x212_ThinkstockPhotos-515056570

‘Sure I know they’re trying but are they…? Really?’

I even found myself saying it at work to be told it wasn’t good enough. That can be hard especially when you’re being held to account for things that are out with your control. I know I’m not the only one who has experienced this from what I see discussed on social media (Professor David Oliver’s tweets from the weekend are a good starting point @mancunianmedic)

Medicine sometimes feels like a giant mechanical beast to be dissected and analysed. We’re very good at coming up with diagnoses, tests and management plans. We’re great at refining ‘process’ when things don’t go well. We also have a complaints department whose job it is to write letters with our findings. It’s all very…. clinical.

Where is the feeling?

I’ve been a supporter of Patient Opinion (@patientopinion) for years. I love its simple concept of real time feedback. I have become increasingly frustrated and disillusioned with the clunky, time consuming/wasting complaints process on offer to patients and families. Patient Opinion allows people to share stories – good and bad. It allows us not only to be transparent and honest but also lets us share with the whole team. It opens up the possibility of real time change in a way that the current system doesn’t.

po_header_logo_footer

This ability to effect change in real time I think is crucial in maintaining the trust of patients and their families. I also think however it has a role in protecting the emotional well being of the team.

A colleague on twitter Dr James Fisher (@JimboFish) introduced me to Schwartz rounds (@PointofCareFdn). The idea is again a simple one. While we can do a significant event analysis we rarely focus on its impact on the team from an emotional perspective. We don’t talk about the frustration of dealing with an agitated delirious person who we wish would just sit down in case they fall and break a bone. Or how we felt being shouted at by angry relatives in the middle of the ward. I understand their stress and worry but does that mean they can call me all the names under the sun and twist my words….?

I tried to introduce this to the post take ward round debrief when I was on call this weekend. After going through the job list I asked Tania, my FY1, was there anything else we should or wanted to talk about. It turned into a discussion about the non pharmacological management of delirium. We spoke about trying to change perspectives to see through the eyes of the person we are trying to help. What was amazing was the realisation that actually the most helpful things are often the most simple and easy. Feeling empowered she went off to put into practice what we had spoken about. All with a renewed sense of confidence.

Having tried a modified version of it on call I’m thinking of making it part of our weekly multi disciplinary team meetings. I think emotional vulnerability is hard especially in an organisation such as the NHS. However if we are entrusted with the care of the most physically and mentally vulnerable – sharing our own emotional vulnerability can only be a good thing.

Resources

http://www.patientopinion.org.uk

http://www.pointofcarefoundation.org.uk

http://www.scottishdeliriumassociation.com