You can usually tell the mood in the department early on, right from the peripheries. When it's busy, patients sit in beds out in the corridor; specialty staff are stuck down in the department; the waiting room heaves and it is standing room only. Tempers flare. And, factually, it is worse for patients.

Sometimes, in this mess, the word “difficult” (or challenging or rude or...) gets brought out. Because some people end up expressing themselves loudly, and that is intimidating. Lots of them express a fear of getting lost in the system. When it is crowded, and it's taken longer than they expect to be seen, a few people have come up to staff to make sure they haven't been forgotten. (They haven't, 99% of the time. It genuinely is a stark matter of supply and demand.)

I think it's the same with children who come in with “behaviour escalation”. They fall between CAMHS and medical services, but neither thinks it's their problem to solve. I suspect this is because neither has particularly good solutions for it. Yet they undeniably are “difficult to manage”, hard to put in a box, sometimes end up hurting themselves.

I think all of them just want to be heard.

Even in a district general hospital, each patient makes up one of 60-120 patients in the department at any time. By my estimate, I spend maybe 20-25 minutes actually seeing and examining patients; the rest of the time is spent in front of a computer, so away from patients, documenting, referring, requesting scans, chasing bloods... All “behind the scenes” work, and from the outside, looks like inaction.

How do we fix this? Can it be fixed? What happened if patients were given a more granular breakdown of progress? How do we even communicate the hundreds of tiny steps needed to decide on disposition? How do we make people feel heard?

#reflections #clinical-communication

First concert event of the year the week before last.

Unusually, we had training earlier in the day before the concert in the evening – a nice touch, I thought – meant that we could practice on site. also, because it's hard to get mojo barriers (the crowd barriers that you find at concerts), and our mockup has been broken multiple times by larger members of the team. As I've found, I've found it hard to mock-up, or break down, the physical skills and movements for the thing that worried me most – crossing crowd barriers. so I've been winging it, basically.

As luck would have it, I was placed in a team with the tallest people around, both during the training and the actual event…

The height difference is usually nothing more than a funny quirk, a visual joke. Sometimes even a benefit. Tall members mean they can reach and see things I can't, or catch me where I'm weak. And it was good for those pesky barrier crossings because they could spot me.

Halfway through the main act though, I realised the two tall lads were talking to each other, then to me as an afterthought. It's easier for these tall guys to take up space, to be noticed, to be recognised as The Medic. More of an art to deflect attention.

MRT days make me mindful to be assertive. I am naturally quite soft-spoken and averse to conflict. But the more “go with the flow” I am in MRT, the easier it is to ignore me. Not that I must be heard at all costs. But this extends to being kept in the loop. As much as I can interpret my team's actions because we have a shared mental model, I appreciate sharing that communication…

*He's a student HCPs, and I find they fall easily into a clinical lead role. Those who started volunteering as first aider without necessarily a clinical background tend more to find the operator role more natural, I think.

When you're physically small, it takes effort to occupy space and be heard and lead. Especially when it goes against your own nature. It's not just an amusing look…

#crowdmedicine #MRT #volunteering #personal #reflections

searching for guidelines for an audit for children with learning disabilities and it's low key depressing how many of those guidelines are focused on * behaviour that challenges *

many times I feel like a lot of health and school measures are for the convenience of the adults, but this is saying it as someone who doesn't need to stop these children from throwing things or hitting/biting/kicking other children.

there are also precious few guidelines on chronic pain in children that aren't condition-specific, which is vaguely interesting.

#pain #paeds #reflections

I have two days off after a weekend on call with a steep learning curve, so my brain does need that break.

Just writing some reflections and portfolio sign offs now and thinking

It was pretty fitting that one of my first big learning events was recognising when people were actively dying. That was something I was afraid of, starting off – knowing what was reversibly unwell and what wasn't, and with all the things around that: discussing when people might not survive resuscitation; when to make the call to involve palliative care.

Being in Frailty has helped with making these conversations much more common, and led by seniors used to making these decisions compassionately and sensibly.

Listening to the palliative care team was an education. Listening to how they navigated difficult conversations and family dynamics helped show a way that was calm and clear about uncertainty. In medical school, palliative care teaching was often about generic “breaking bad news” and prescribing. Let's be frank, most of my “palliative care revision for finals” was 80% prescribing, 20% “soft skills”. Learning about palliative care in FY1 has been 20% prescribing, 80% communication skills and styles of patient assessment.... like most other clinical specialties, really!

I have no answers. Coming alongside people and talking about this with them is becoming a bit easier with practice, especially when I know it can be done with compassion and gentleness.

#geris #palliative #death #reflections

small reflections from the other side

I've just finished a run of nights off the delirium ward

I now see delirium everywhere

where before it was “agitated confused” or “drowsy confused” I now recognise “hyperactive delirium” and “hypoactive delirium”... and I see the dangerous transition points where valuable information gets missed, or plans are never actioned.

#geris #reflections

When I moved to this ward, I was struck by how long people stayed on.

But, actually

it's been quite good to know my patients so I could tell other teams about them from memory

And to contact families so regularly that we need only update them on small, granular things – and until they recognise my voice

Continuity, eh

#geris #reflections