Doctors, the world over, are reeling. The global telegraph has been alight with conversations, most of them uncomprehending, shocked, dismayed, fearful. In several swift and definitive decisions, a UK paediatric trainee, Dr Hadiza Bawa-Garba was not only erased from the GMC register, but charged with manslaughter. This was in response to several medical errors – most of them oversights when the details are examined – which contributed to the death of a child in hospital. I have no intention of going through the case here, which has been expertly picked over by a good many sources. Suffice to say that Hadiza was slung to the lions, the consultant in charge leaving her naked, her hospital, her trust, the regulatory bodies entrusted with safety of both doctors and patients, all turning their backs to leave her to her professional demise. All for several decisions made when she was covering extra shifts, in a climate of heinous understaffing, and trying to manage a deluge of patients when she had just that day returned from maternity leave, unsupported and abandoned to her fate.
So much is baffling about this case and its horrific outcome. Nobody wants a child dead from misadventure. It is tragic beyond the reckoning. But for the regulatory bodies to kick back with the tendon strike and sacrifice an individual so? Is Hadiza supposed to be an example, like a spiked head at the entrance to the Thames? Unquestionably these decisions will serve to endanger patient safety in the future. Individual blame always does this, driving self-reflection and honesty underground.
Hospital systems are almost incomprehensibly complex. Patient safety is paramount, but the infinite interactions that occur within them will likely always outfox the desire to provide foolproof polices and structures. You can’t legislate for the illimitable.
The outcome of this case is extreme, but so many of the occurrences are commonplace. Without any desire to misappropriate a worthy movement, is this another instance of #MeToo?
We inside the beast are always going to make mistakes. Always. Most of them are small; oversights, errors of judgment, succumbing to biases, betrayal by the impossible circumstances in which we sometimes work. Most picked up by the lumbering checks and balances designed to avoid them.
No doctor ever wants to make mistakes. In fact, cheered on by cases like Hadiza’s, we, and the world we serve, see medical error as utterly unforgiveable, a deep personal failing. Doctors, for many reasons, are not very good at failing. I know what it feels like. I expect my experience is nothing special, but I know what it’s like to wake repeatedly in the early hours, my gut twisted and writhing re-asking myself why I thought a certain thing, or missed another. I know what it’s like to hide in the department toilets, trembling and wiping away unstoppable tears. I am on intimate terms with disgust. I know what it’s like to think, perhaps if I end it all… I know what it’s like to stopper in the shame and humiliation that comes with the perception of not being good enough. Mostly our punishment is a deafening, roaring monster within ourselves. And, if we are very, very lucky, we get a system that allows us to self-reflect, even better with some empathetic human support, and even better a respectful, inclusive way to analyse the system errors, which, almost always, are more contributory to any error than the part the individual played.
I’ve thought a great deal about the consequences of medical error. I wrote a novel about it. It’s the core of Dustfall. If perhaps a handful of people read the book, either medical, or not, and see into the heart of a doctor after failing a patient, then perhaps the six years of sentence struggling will be worth it.
I may have been a little overwrought. By lauding the kidneys over the lungs in the last post, it’s possible I’ve done the body-bellows a disservice. So I resolve to address this. Today we shall examine reasons why the lungs, if not winning first place in the organ stakes, at least get a solid participation certificate.
There’s the obvious reason we like lungs. The whole oxygenation thing. Goes without saying, that’s cool. Plus the reverse removal of carbon dioxide. Sure. Great. We get it.
And yep, they do that half-assed, kind of flashy job with acid-base equilibrium (not to harp on, but nothing on the kidneys). Compensation, buffering, yada yada.
But, if we’re going to applaud the air-bags, then we should appreciate their more eclectic functions. After all, who wants to be known as a work-horse when you can be avant-garde?
Following are several of the lung’s more glamorous responsibilities:
- Clot filter. When any muck, clot, or alien sort of material starts a-rambling through the vasculature, the immense pulmonary capillary network acts as a mostly impenetrable mesh, a fine sieve, a Gandalfian passage prevention kind of scenario. Which has raised the fairly recent question, in the light of our drunkenly lavish use of imaging, whether small pulmonary emboli are, in fact, a normal phenomenon. Lung lint, as they are amusingly alliteratively named. And, you may recall, lungs are a rich exuder of tPA and heparin like substances – helping melt away the coagulated clumps.
- Lung as pawn. First line of immunological defence. Unlike the pawn though, the lungs have a staggering arsenal of protective mechanisms: a mucous blanket, a muco-ciliary escalator escorting inhaled foreign bodies back out the way they came, ravenous macrophages swallowing everything even slightly alien in a liquid eighties pac-man style, and hundreds of other immunomodulatory functions.
- A dizzying array of metabolic functions – molecules passing through the lungs have a high chance of being modified, activated, broken down, gender-switched and so on. I suspect we have hardly a clue as to the depths of activity going on in the dead of the thorax when we are not watching.
- And, for the most surprising piece of new lung knowledge in 2017, some intrepid researchers from San Francisco discovered that the lungs produce up to 10 million platelets per hour, dwarfing the sluggish production line of the bone marrow. (Ed. note. One of the principle researchers was Mark Looney. I submit this without comment) (and who am I kidding. I am the editor. I was just trying to deflect such an infantile addition).
But let us move on from such dry physiological periphrastic discourse.
I have a story about lungs. It is not very pleasant. I have previously written about the German student exchange I endured when I was 16. My host family were not overly keen on having an exchange student, and they were quite fond of laughing at my expense. We were out to lunch one day just south of Nürnberg, and I was given a menu off which to order. My linguistic skills were lamentable. I recalled ordering an item like pinning a tail, blindfolded, to a donkey. It was lüngerl (or something similar). The family sniggered. I was wary. The dish came out, gravy brown and chewy, like a tyre stewed for 3 days in a steaming bog. I persevered. They laughed. Friends, lung is not a gourmet food.
Allegedly respiration was first described by an Arab physician, Ibn al-Nafis, in 1243. In the first half of the 16th century, the role of the lungs was thought to be to cool the heat and rage of the heart. In the next century, William Harvey, that most sensible of chaps, finally started to work out what the dickens was going on with them. The real Dickens speaks of our organ in Oliver Twist: “It opens the lungs, washes the countenance, exercises the eyes, and softens down the temper, said Mr. Bumble. So cry away.”
The lungs of vertebrates are evolutionary relations of the gas bladders of fish; in their most rudimentary form a simple outpouching of the oesophagus, allowing storage of a gulp of air in oxygen poor situations. Spiders have what is known as book lungs, and if I had to choose a type of lung, that is definitely what I would go for. Lungfish are ugly. There, I’ve said it.
A surprising number of songs have ‘lungs’ in the title. This includes Florence and the Machine’s Between Two Lungs and Megadeth’s Into the Lungs of Hell (if you were looking for a night lullaby for your children).
Now this is not a post about pathology and disease. We’d never get out of here if it were (and I can hear you straining to do so already). But as a last word, let us take a look at the lungs of some of the great writers. They were a pack of wheezing, dyspneic artists if ever there were, coughing their bloody expectorations delicately into their lace handkerchiefs. Proust died of asthma complicated by pneumonia, Keats, Katherine Mansfield, the Brontes, Chekhov and legions more succumbed to TB, Updike was carried off by lung cancer, and Evel Knievel’s life was (surprisingly, and really inappropriately placed here) terminated by idiopathic pulmonary fibrosis.
Thus, I end with an apology to the lungs, demonstrated this by this week’s award.
Thus begins a new series; blogposts to celebrate features of ourselves that are scandalously overlooked. Our internal organs. This will be a collection of pieces drawing attention to our hard-working innards, a compilation that will be barely educational, seldom beneficial, and not even remotely weekly. But I do so love the complex machinations of the bits that make up our bodies, and I thought I would like to write about them.
So first, the kidney. But why does this liver-coloured bean get first place? The gold medal? Let me count the ways.
The kidney is the modest and loyal guardian of the internal milieu. Unlike the flashy lungs, who, at the first hint of acid-base disturbance get all huffy puffy, the kidneys are slow, considered, and in the case of respiratory alkalosis, almost completely capable of returning the pH to normal, a feat the lungs can only dream of. Yes, the lungs may be quick to blow off CO2 in metabolic acidosis, but they bore easily, never quite finishing the job. The kidneys, on the other hand, quietly get on with their lumbering business of bicarbonate and proton shuffling, restoring neutrality without fanfare.
The derivation of the word kidney is joyfully obscure. It comes, possibly, from the root words for belly, womb, and teste. The proto-Germanic (and once again, bless that amusement park of a language) has kidney and testicle freely interchangeable. Allegedly it is also an obsolete, slang term for waiter.
Talking linguistically, when learning of the peripatetic ways of the internal workings of the kidneys and their tubules I first heard the term, and you may well be the same, countercurrent mechanism. What a joy! One could picture the molecules marching in and out of the newly sprouted urine, up and down the nephron, following the concentration gradient the way a retiree with a caravan chases the sun. Marvellous! Evolution is a crazy wonderful thing.
Humans can live perfectly well with a single kidney. Subsequently they have been the source of some fabulous urban myth stories about hand-written notes, telephones, and ice baths. On the sobering side, it means that organ trafficking is a dire global problem. Iran remains the only country where it is legal to sell one’s kidney – a legally traded kidney fetches several thousand dollars, but on the black market prices balloon to hundreds of thousands of dollars.
Your kidney can smell (allegedly). Or perhaps, more accurately, it sniffs at the urine as it gushes by. This marvellous fact was discovered by Jennifer Pluznick, a professor of physiology at Johns Hopkins.
Speaking of receptors, there are, almost definitely, hundreds, possibly thousands of different receptors on each nephron. And there are at least a million of these itty serpiginous pythonesque things per kidney. One can only read this, slack-jawed, and realise that we have barely begun to understand all the functions of this beany beauty. We are but toddlers in our knowledge.
The primary function of the kidney is, of course, to jealously guard the creation of the golden waters – to perfect the concentration of them, compared to plasma. The kidney is the gatekeeper, the demilitarised zone, the border patrol, policing the movement of all manner of molecules, in order to produce a perfectly balanced cocktail of liquid waste.
Allegedly it is edible, with steak, in a good pie, although I think that the human variety may not be the ideal ingredient.
For all its good and wonder though, it is a rather savage stonemason, and concretes small rocks into existence, made from various concentrations of calcium, oxalate, phosphate, uric acid, and cystine. It’s also been known to carve brick red stones out of xanthine, and struvite, which resembles glass crystals and can occasionally be found, disconcertingly, in canned seafood.
The above features are but a tiny fraction of the wonders of the kidney, its function and dysfunction, but it has given me great pleasure to award the kidney the title of top contender for organ of the week. I hope you’ll join me in a round of applause for this sensational viscus, however I’d be surprised if any of you have got this far. Please do add any nephrologically fascinating facts if you’d like.
Let it never be said that we resist change. We, the consultants in my ED, have been reinvented. Previously our title was Duty Officer, which had a pleasantly communist, scratchy grey-overalled sound to it, but now we are the EPIC. An imperious title, in my opinion. This stands for Emergency Physician In Charge. Here’s where the duplicity begins.
I’m hardly in charge of my own brain, so feigning tight command of the beast of the Emergency Department is a bit of a stretch.
But still, I turn up for shifts. At least I dress appropriately. I wear scrubs which make me look like a scrawny Police Officer but without the fun stuff hanging from my belt.
I carry THE phone. Yes, the one that has the broken ice-cream truck ring tone that peals out horribly during the depths of sombre conversations; the phone that conveys endless information bytes about patients who may, or may not, pass through our doors, or otherwise random requests or facts upon which I am allegedly supposed to act. With this, though, I am firmly in charge. I don’t answer it. That’s the limit of my in-chargeness, I think.
The days vary, like all good days in the vortex of Mount Doom. Let’s take one.
I start it by thinking about coffee, which is then rudely interrupted by waves of patient chaos. Busloads of them and their relentless pathology. By nine I am wondering whether I am coming down with some rare form of illness, perhaps vasculitis, or takotsubo cardiomyopathy, but it turns out I just want coffee.
I am supposed to be at, or possibly in, a huddle. I don’t know what a huddle is. I find out it is a meeting with people who are pivotal in managing patient flow, who will tell me exactly the number of beds we don’t have. Some people will get told off. I don’t get told off, because I don’t know such meetings are being held. And I don’t answer my phone.
Next the bat phone goes off. This is good, because this is what we train for. The registrars go head to head, fighting to answer the phone, because whoever answers it gets to run the code. A registrar is injured in the elbowing melee. They need to go lie down in resus. As I am puerile I announce the incoming code over the tannoy like an airhostess. No one is amused.
The code is a patient with crashing sepsis. Because I am so epic, I am not allowed to touch the patient. I look longingly at the patient’s veins, and imagine slipping a central line into the subclavian to a round of applause, using only landmarks and the fairy dust of a clinician who has been around for so long that they have a sixth sense where these structures are, like a Baggins in the Shire. This does not happen. The registrar slides the CVC in with exquisite skill, brandishing the ultrasound probe like nun-chucks. He does not need applause.
By now my need for coffee has become sentient, and is talking loudly in my head and causing hallucinations. I decide I will have to drink the hospital brew. Sadly, our hospital cafeteria has insisted that the coffees need to be reproducible, so they have replaced the baristas with an automated grinder. I am not joking here. Something about benchmarks and KPIs. For coffee. At this point it doesn’t matter. I am prepared to drink anything, and don’t judge the drink for its dystopia.
I am ready, then, for the next patient (keeping in mind that I am so epic I know exactly what’s going on with every single one of the rest of the 45 patients in the Emergency Department – what their plans, vital signs, and backstories are, as well as the reasons for them breaching some weird militarily-enforced time-target. How do I know? Well that is the secret of being epic). The next patient is a trauma, a rather bloody and moderately deconstructed victim of speed and inattention. This time, I get to watch a registrar running the trauma, who is doing something called a work-place based assessment. This seems to be a mechanism designed purely so someone as garrulous as me is forced to shut their mouth and watch a trainee perform. In this way I can constructively educate and assess the registrar at the same time. My hands are so itchy to get in there and be involved in the intimacy of patient care they could be weeping in my pockets. The registrar does a fabulous job, and I have only interrupted her about eighteen times. The patient does fine.
I’ve had enough. I want to see a patient myself. I sneak into a cubicle and stealthily close the curtain, where I begin to take a history from a fabulous old man who has been waiting (patiently) for 3 hours to be seen, who is telling me where he fought in the war. But now I am hauled away to a meeting, because I wasn’t smart enough not to answer the phone. I am in trouble. They ask me why it’s taking so long to see the little man who fought in the war. I would like to make a witty joke about the irony of this, but the people with clipboards don’t look in the mood for a joke.
Basically the day continues like this. Sometime after lunch I feel I would very much like a nap. I look plaintively at the distressed relative’s room, and wonder if I could jigger the lock so I could have forty winks, but the phone rings again.
I am surprised by the variety of requests that come through on the EPIC phone. Mostly my job is to try and concoct an answer without getting too cross. Often the answer will end up being of little use to anyone, but I have learnt to phrase things just right so nobody knows that until well after they’ve rung off. A resident calls in sick. This is bad, because it now leaves the number of residents to staff the evening shift as a negative integer. We are suffering from junior staff cachexia at the moment. Everything has been downgraded. For political reasons our hospital has been repurposed and rebranded. Where we used to be the state’s top dog, we are now the punchy little sibling. Things may well change, and it is likely they will. Working here for decades has made it clear that the health ride consists of the dizzy peaks of the rollercoaster interspersed with the gut dropping lows, complete with arms flailing and eyes squeezed shut (or that could just be me). I am immensely proud to work amongst a team that has hung in there, undistracted for the most part by the flighty decisions made by health bureaucrats. The professionalism and commitment of my brethren to patient care has never wavered.
And then, just like that, the day ends. My shift trying to keep the lid on the bubbling pot of entropy is done. I hand over the phone. Someone else gets the chance to be epic. And I’m sure they will be.
This post originally appeared on Life in the Fast Lane.
There’s a torso at the front of the queue. Towards the back of the line, patiently waiting their turn, are several uniformed staff-members. Some of them are cracking their knuckles. They mean business. Well one doesn’t, but he’s a first year medical student with a sweat sheen on his upper lip and a hairy look in his eyes, clutching a wilting assessment form. The current contender bouncing on the sternum has forearms like roo tails and there’s a quiet admiration from the entire team. She’s managed to get the end tidal CO2 so high Al Gore would be outraged.
Me, I’m just perplexed. I’ve lost count of where we’re supposed to be in the sequence. We’re somewhere in the midst of an alternate cycle, so, I think, we are drugless and ready to charge. I don’t want to announce my heresy by questioning the algorithms out loud (writing this I have realised how close the name Al Gore is to algorithms, and I wonder if there’s an essay in here? A sort of linguistic marriage between fame and medical terminology? No, sorry, you’re right.) I’m lucky though. It doesn’t matter if I am struggling to follow the ACLS recipe, because everybody else knows exactly how to count in the actions, like being the next one to enter a kid’s skipping game.
The correct person at the precisely correct moment dumps an unwanted charge. I wonder for a moment where the rejected electrons have gone, but then another command hauls me back and everybody rotates, cranking up another round of the chant.
I’m sure I’m not alone experiencing an odd derealisation whilst running an out of hospital cardiac arrest. There’s the human underneath it all, of course. The bone white legs, a bloodless hand hanging unheld off the bed. A husk of a person gilded by the twilight sun streaming through the high windows. I don’t want to make light of it, for that patient, for these final violent moments. For a family gutted to see their loved one on this precipice of life and death. But the ritual of CPR? What a strange biological liturgy.
Imagine the body as a theatre. It’s the heart only under the spotlight. The audience is transfixed by its monologue, unaware of what’s going on in the wings. We applaudingly compress the myocardium like a metronome, and every so often bathe it in a drug that doesn’t work and then shower it in sparks. Left unnoticed the rest of the body goes all Lord of the Flies. We have a fair idea what anoxia does to tissue – can you picture the anarchic storm of molecules billowing up offstage? The rest of the body’s going to hell in a handbasket, and we only have the myocardium in our sights, hoping to stop it progressing from flab to stone. We have a few blunt tools, but our ACLS teaching lulls us into thinking of them as fine instruments, wielded at exacting moments in a protocol. Eyebrows are forcefully raised if deviations occur.
It’s not that conventional CPR doesn’t work – it’s the most effective technique we have to keep the heart sated and blood trickling to the other organs like a drink in the desert, until the defibrillator delivers the reboot (the best ‘have you tried turning everything off, then turning it on again,’ method), or a reversible cause can be identified (the new spar and parry spectacle between echo and compressor), or, in the fanciest of places, a diminutive machine attached via the way of hosepipes which can do the living for a bit. It just doesn’t happen that often. Great that we’re all speaking a common language, but having confidence in what we’re achieving? Ah, therein is another matter.
And, like a thousand Shakespearean ways to die, each arresting heart comes at this grand finale via a different route, along different time scales, and, ultimately, different needs at this rather pointy end.
There are things we do know for sure – pauses are bad, so if you’re going to have any hope, do it well and do not stop. Pre-hospital, bystander CPR makes a difference. Defibrillation works for VF. Adrenaline? That argument is best had down the bottom of a rabbit hole.
It reminds us though, that we, like Socrates, know almost nothing. So much is ahead of us to discover, in so many areas. How wonderful that in the first half of 2017 we have learnt so many extraordinary things about such varied areas; that the mesentry itself is a complex organ (after so long considering itself just a yolky bowelhanger prone to embarrassing plumpness in middle age), lungs make the majority of our platelets, and there are taste buds in our lungs as well as testicles. It feels like being in medical kindergarten. Are we on the cusp of unearthing a subatomic explanation for bodily functions? After discovering that there are quantum effects in the way plants photosynthesise, scientists have become very interested in qubits in consciousness, or entangled quantum bits of information, and that perhaps our wet, mushy biological systems can be better understood by nuclear physics. Exciting times, for sure.
Which brings us back to ACLS. Basic in principle. Simultaneously brilliant and terrible. CPR, same (no cats in boxes jokes). For hearts whose futures are irredeemable (if only we could convincingly know, besides the obvious, which ones these are), it is uniformly awful. So one mustn’t feel too guilty about questioning the rigidity of the guidelines. Although they are currently based on best evidence, and give us a useful common parlance, the truly effective interventions may be many moons away. The heroes in all of this are not the providers in the queue, or the chef calling out the menu, but the scientists and researchers, beavering away, coming at solutions creatively. Until we have better, however, we need to go back to queuing up, modestly and mostly obediently, with our sleeves rolled up.
This post originally appeared on Life in the Fast Lane.
I’m not sure how we ever used to manage multi-traumas. We must have been frightfully underprepared. Back in the days before mandatory training we relied, rather guilelessly, on experience, a suite of knowledge from texts and journals and M & M meetings, the good-will of a team, and the wisdom of our trauma specialists. A precarious position, you’ll agree. And an area where you were never entirely clear whether you, and what you did, were good enough.
Now, thankfully, we, as employees, are standardised – acceptably and holistically checked off. Benchmarked and compliant and up to date with our mandatory on-line modules. This is good. Most aspects of emergency medicine are chaotic and messy enough as it is, seriously in need of a good digital check-list groom, let alone considering trauma, that most unpredictable of diseases. Trauma is another grade of disarray altogether. Anarchy held together by skin.
The beauty of on-line modules is the certainty. And the reproducibility. It is beyond edifying to know that the person working next to me is signed off as competent in accountable decision making, and I know they can safely handle a patient over a certain weight-grade. I can be confident the web spaces of their fingers are flawlessly washed and germ-free, and that they have practiced a variety of safety stances in the case of impending violence. They are, in the eyes of our executive, trained.
Although this does bring us back to the consummate violence – the type manifest by our major trauma patients. These patients are so damned disordered. Internally dishevelled. Disobedient. Take your eye off them for a second and they’re setting off fireworks somewhere in their innards, right where you didn’t expect. So we don’t. Take our eye off them.
Trauma is the ultimate team sport, best played with the slickest and most integrated, respectful team, peopled by the most experienced team members possible, running the shebang from the moment of the traumatic event somewhere in the giddy light-filled outdoors, sliding through the corridors of ED, then off to their various destinations; the end string of the maze chosen efficiently by leaders with a beady eye on the patient’s belligerent biology. But these people, these team members, seriously worry me. I have a growing suspicion that not all of them are up to date with their mandatory training. They seem to embrace uncertainty. Are comfortable with it. Are able to work within it and make quick, dancing decisions based on all sorts of unmeasurable factors. This simply will not do.
No. The tremendous sequel to the staggering increase in administrative staff over the past decade has been the glorification of the black and white. Nowhere is this demonstrated better than in the increasing production of mandatory on-line modules, and the reliance on these as a tool for signing off hospital staff as being compliant and competent. Time well spent, I can hear you all cry. What better way to prove that you are proficient in managing complex patients than by spending precious hours taking quizzes on terabytes of information about the muster points for a fire in the café? I know I’m not alone when my heart leaps a little with joy if I make a single error on the quiz, thus allowing me to return the start of the information package. Who wouldn’t rather read how to operate the hover mattress than a discussion of the nuances of trauma induced coagulopathy? Let us all learn to play chopsticks, not Chopin. No gaming or glazing while doing these tests, that’s for sure.
But, you say (rightly calling out my unseemly sarcasm), you have trauma meetings, missed injury reviews, audits and registries, discussions with colleagues and debriefs, to ensure you’re at your most capable. Yes we do (and thank the deities for these). Mostly, however, these are voluntary, certainly for the individuals within this vast swirling system. No. The only thing the institution expects of us is printed off, signed off, grinning compliance with the mandatory on-line education. And these are not the only digital incursions we must fill out, sitting lachrymose over our congealed coffee. The Working With Children Check (otherwise known as a ‘tax’) (a biennial, utterly baffling piece of bureaucracy that requires an ACTUAL visit to a post office), on-line credentialling at hospitals we have worked in for years if we want to even sneeze inside, and just when one’s hair is ready to be torn from its roots at the internal agony, an online mandatory training module for resilience and mindfulness (not yet at my institution – the irony bar has not yet swung so low).
It sometimes feels like a war. Us versus them. Complexity versus simplicity. Unmeasurable versus yardsticks. Commonsense versus the absurd. It shouldn’t be. Our goals should be aligned, we clinicians and non-clinicians – to provide the best patient and community care, approached sensibly, with respect enough that neither party should waste time on activities which do not contribute to either. We should not both be drowning in madness, in either the thick, or the administering of it. We await the return journey of the pendulum. In the meantime, it’s back to the mostly, unquantifiable mayhem.
This post originally appeared on Life in the Fast Lane.