I’m allergic to quinoa – allergy, intolerance and NAP6


A friend of mine recently posted probably one of the more middle class new age Facebook posts I have ever come across, saying that she had been reminded of her allergy when she mistakenly ate quinoa crisps rather than hummus ones. I resisted going on my soapbox for a bit but in the end couldn’t resist, and calmly explained the difference between an intolerance and an allergy. It also made me think and spurred me into putting fingers to keyboard, mainly just to get this allergy thing off my chest a bit more.

Some of you may have been aware of the launch of the sixth national audit project (NAP6) by the Royal College of Anaesthetists (RCOA) a few weeks ago. This was an impressive project where every NHS hospital in the country participated and reported every single anaphylaxis during anaesthesia through the study period. Interestingly only 13% of private hospitals participated despite being written to repeatedly by the president of the RCOA – a figure that should make the private sector hang their head in shame.

Anaphylaxis is a life threatening immunological reaction and the most severe form of any allergic response. The immune system goes into overdrive, releasing substances that cause generalised swelling, breathing difficulty and constriction of the airway. The blood pressure drops dangerously and without fast treatment the results can be fatal.

The audit project came up with some interesting results: the drugs most likely to cause anaphylaxis were the antibiotics, and of them teicoplanin was 17 times more likely to do so than alternatives. We often use teicoplanin for patients allergic to penicillin, believing it to be a safer alternative, however more than 90% of those who think they’re allergic to penicillin aren’t, and we may be exposing them to greater risk by giving teicoplanin. What was reassuring, though, was that most patients who developed life threatening anaphylaxis survived, and fast action by anaesthetists diagnosed and started emergency treatment within 5 minutes in most cases.

One of the ways we try to prevent allergic patients not receiving the drug they are allergic to is with the red name band system. Normally the patient’s identifying name band is white, but for those with a severe allergy a red one should be used, as an additional reminder to be careful. In recent years there has been a lot of discussion in the media about “food allergy”, and many patients I treat have a long list of things they are allergic to.

Except almost all of them are not.

If you get abdominal cramps from eating quinoa it does not make you allergic to it. You may be intolerant, yes, but not allergic. Yet there is often a red name band. Some of the common “allergies” seen on red name bands include hay fever, intolerance to gluten, eggs, milk, being a vegetarian, religious food stipulations and many others.

It has reached a point where so many of my patients have a red name band on that the visual reminder that it is supposed to give me is entirely blunted, defeating the whole point of the system.

So I want to make a plea:

If you think you’re allergic to penicillin but don’t know exactly what happened, you’re probably not. Why not get yourself tested and then you’ll be able to be treated with antibiotics with fewer side effects, which are often very much more effective than the alternatives.

Please don’t use red name bands for hayfever, intolerances etc. We ask about allergies and intolerances when we discuss the anaesthetic with the patient, but the red band is to warn me of a possible serious reaction. It should be rare to see a patient with a red name band.

Also, have a look at NAP6 – if you’re a professional the full report is available here, but there is also a nice summary infographic here for those short of time.

And finally, if you’re in private sector hospital management please increase your engagement in these audits. Many private sector institutions do not have an anaesthetic department or any clinical anaesthetic leadership. A strong, proactive anaesthetic department is essential to any hospital and increases the strength of governance and safety.

I’ll get off my soapbox now.

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WhatsApp Doc?


This year London has had its fair share of major incidents with the Westminster and London Bridge attacks, and most recently the Grenfell fire. On these occasions we have activated our well thought out major incident plan, and each time analysed what went well, and what we could improve, and debriefed our teams. 

At the final Westminster debrief there was some discussion about the use of our personal mobile phones and WhatsApp to improve communication within our teams. During the meeting I set up a WhatsApp group for the anaesthetic consultants for use only in major incidents – it took me two minutes, most of my colleagues were broadly supportive, a couple immediately left the group and a few others mentally rolled their eyes at yet another group that was going to ping on their phone and generally annoy them. 

When I was woken by the major incident phone call at 3am on the 14th June I looked at my phone and there was already a lot of activity on the WhatsApp group, colleagues offering to come in, directions on where to report to and what needed doing. I looked out on our terrace and was met with an awful sight of West London lit up by the Grenfell fire.

 Image courtesy of Paul Barlow
Our hospital’s response to the fire was very well coordinated and effective, but I was particularly proud that the information sharing and general coordination of the anaesthetic department was second to none. Other teams looked on us with envy and the central coordination team was asking me for updates on how things were going. Anaesthetists are central in the treatment of any critically injured patient, and in the management of multiple casualties it is vital to have the anaesthetist and ODP/anaesthetic nurse in the right place. WhatsApp was absolutely central to this and made team coordination simple. 

Despite being against most NHS information governance rules, WhatsApp is used routinely every day in the NHS for communication within teams. I’m glad to say that no patient identifiable information was shared in or Major Incident group but I know such information passes within clinical team WhatsApp groups up and down the country every single day. Is this a contravention of information governance principles? I would say no, as long as professional safeguards are applied. 

WhatsApp is end-to-end encrypted, meaning that the only way of viewing those messages is on the smartphones of the members of the group, and hacking into the messages is otherwise pretty much impossible, so security is dependent on the group members having encryption on their phones and treating the information they receive responsibly. Many of the concerns expressed about WhatsApp involve irresponsible behaviour – what if they share the information on social media? This would be no different to taking a set of notes and leaving it open in the hospital cafe for everyone to see, and contravenes the GMC’s excellent social media guidance

Why doesn’t the NHS spend a lot of money on setting up its own social media platform to mirror WhatsApp where you can share patient data then? I would argue it would be a waste of money as the platform already exists and is already secure. In addition the NHS platform wouldn’t have the resources to be kept up to date with new operating system releases and would soon enough become less secure and more prone to attacks. Also, new, convenient features get added quickly to WhatsApp but would be extremely slow to get into any bespoke system. 

So should the NHS embrace WhatsApp communication? I would say yes, but there needs to be guidance on it. It is the responsibility of healthcare professionals to treat that information confidentially and with respect, to have their phones encrypted and to delete information from groups after they move to a different job. We need to accept the reality of WhatsApp and all the benefits it brings us, but need to provide sensible safeguards on the way it is used, and to treat unprofessional social media behaviour in the same way as leaving a set of confidential notes on a park bench. 

In the meanwhile, I hope my Major Incident WhatsApp group stays silent for a while now.

In praise of Prepare surgery and the Imperial Charity


I have just finished packing my bag before doing some insanely stupid 24 hour hill climbing thing tomorrow in aid of our Prepare for surgery programme – a simple idea where we train our patients before their major surgery so they are fitter, healthier and more motivated than they were before we started it.

One of my frustrations in the cash strapped NHS is that it is very difficult to get funding for innovation, even if it will reap savings in the medium term we do not have the capital funds to make these projects happen as we are already in deficit and have to balance the books by the end of the financial year (or rather minimise the imbalance in the books). It stifles creativity, crushes our desire for improvement and instils in us a learned helplessness where we eventually just do things the same way we have always done them and stop trying.

I’m very fortunate to work with some inspiring people who refuse to let this attitude affect them and find ways of funding their excellent ideas, and Prepare is no exception.

This is where the Imperial Charity comes in, with a refreshing open attitude and money to give out they fund great ideas and allow projects like Prepare to become reality.  The benefit of their funding extends way beyond the borders of Imperial itself, as the project is being taken up in many places throughout Europe, and I think will change the whole way we deal with preparing our patients for major surgery. We have already seen some extremely positive results – reduction in length of stay in hospital and much fewer chest complications, and our patients seem to me much more motivated and involved in their care.

So as I put my softest of soft socks and waterproofs into my bag and head up to Scotland tomorrow to climb Ben Nevis I want to take this opportunity to say thank you to the Imperial Charity and their constant support, and for sharing our passion for innovation and better healthcare.

If you want to read a bit more about what we’re doing and maybe donate have a look here: https://www.justgiving.com/fundraising/PREPAREforsurgery

For more information about the Prepare programme look here: https://www.imperial.nhs.uk/our-services/cancer-services/oesophago-gastric-cancer/prepare-programme

Preparing our patients for surgery. 


Would you run a marathon without training for it? Didn’t think so. So why do we expect our patients to undergo major surgery with just a bit of pre-assessment and a pat on the back?

St Mary’s is one of London’s centres for upper GI surgery – meaning we operate on oesophageal and stomach cancers.  These are big operations with a high rate of post operative complications like pneumonia.  Our patients generally undergo chemotherapy for three months before their operation and usually they lose physical fitness during this time.  

This three month period is also a wonderful opportunity for training. We always told our patients to stop smoking, do more exercise and ensure they ate well during their chemo, but they were essentially on their own.

For the last two years with grants from the Imperial charity and CLARHC we have been taking this further and providing our patients with a training programme cantering not only on physical exercise, but also nutrition and psychological support.  Our patients are more prepared on their day of surgery, they are motivated, fit, better nourished and have a glint in their eye and a determination to get through the operation. Our complication rates have improved (particularly pneumonia) and our patients mobilise earlier after surgery. Our patients are in control and are able to influence their cancer therapy.

This programme is charity funded at the moment for our NHS patients (interestingly several private medical insurers have refused to fund their insured patients to go through it), and somehow my colleagues have persuaded me to join them on the three peaks challenge in June to fundraise for it. For those who don’t know, the challenge is to climb the three highest peaks in Scotland, England and Wales all in 24 hours. I asked if we couldn’t just do a 10km race or half marathon or something like that, but no – apparently it has to be something more crazy. 

So here I am with my begging bowl – the prepare for surgery programme isn’t a shiny gadget, it’s a simple concept that makes sense, and has made a big difference to our patients.  We’re planning on rolling it out to other specialties and hospitals, we’ve developed an app for our patients and for all this to work we need funds.  

The fundraising link is here https://www.justgiving.com/fundraising/PREPAREforsurgery

Perioperative oxygen and surgical site infection.


In November 2016 the WHO produced guidelines on the prevention of surgical site infection. Along with some very sensible recommendations about when to give antibiotics and whether patients should have a bath before surgery there was a section on how much oxygen we anaesthetists should administer to patients during and immediately after an operation. (Section 4.12 in the guidelines below).

http://www.who.int/gpsc/global-guidelines-web.pdf?ua=1

The guidelines state that the group looked at the evidence and then performed their own meta-analysis, and a further subgroup analysis. Some of you may already know that meta-analyses are one of my personal hobby horses. Every trial has its own biases and then we bunch a load of them together in order to concentrate and distill these biases, then do a subgroup analysis to focus on the areas where those biases may have taken the trial results to statistical significance. I can name you many subjects where a meta-analysis has changed our practice only to be disproven a few years later by a well conducted trial. 

I sent these guidelines out to my consultant colleagues and not one supported it. In fact one of my colleagues who is also a medical statistician produced an excellent piece of work summarised here:

They answered the wrong question, looking only at infection rates and ignoring overall benefit or harm to the patient. In a Cochrane analysis Here the chance of high oxygen concentrations reducing surgical site infection was described as low, and in addition there could be a 20% increase in mortality for those patients with high oxygen concentrations. 

So essentially high oxygen concentration may reduce SSIs a little, or it might cause a 20% increase in mortality. Or neither. In any case the evidence is far too flimsy to put this into international guidelines, and there is a chance they may actually cause harm to the patients we’re treating. I won’t be changing my practice based on these guidelines, it’s a shame it’s been included at all as it reduces the impact of the rest of the document. 

Refilling the tank


How can we gain strength from draining conversations?


Some months ago Mike, a doctor friend and I were discussing how end of life conversations affect us. He had recently had to tell a teenage boy’s parents that their son had a devastating head injury after a car accident and was brain dead. Everyone was was overcome with grief the and he found the conversation extremely draining; the parents were lovely, understanding and cooperative, and he identified with them and shared in their grief. Discussing it afterwards, a senior consultant colleague told him “I only have a certain number of these conversations in my tank and I really feel I am now beyond empty”. 

During our conversation we discussed a few other cases, I told Mike about one where immediately after the conversation I retreated to my office and cried for about 20 minutes before being anywhere near ready to work again. Even now I feel the grief of that mother as if it were yesterday, I’ll never forget her reaction at hearing my words, the disbelief, the pain. 

Is it true there are only a certain number of these conversations in our tank? How can we refill the tank or at least limit their draining effect?
I suppose the easy way is to shut out our own emotions: protect ourselves from other people’s grief, limit empathy, separate our work from our personal lives, not feel their pain. However most of us find that difficult. We went into medicine because we care about other people and we want to help them. We enjoy helping people and shutting this out also shuts out our enjoyment of our job, and the satisfaction we gain from it. We may successfully prevent the tank draining out but we also reduce its size, and this method certainly won’t refill an empty tank. 

So we need to find a way of gaining satisfaction from these difficult encounters. How can we possibly make ourselves feel good from the grief of others? Is it right to gain pleasure from end of life conversations?

Recently I looked after a man who came in severely injured, but still conscious and very much aware of what was going on. We had some very honest conversations with him, his wife and his daughter, and he chose to have care withdrawn in the emergency department, rather than go for an operation with very limited chance of success and a high likelihood of permanent disability. The department was busy but we succeeded in providing a modicum of privacy and he died without pain with his wife and daughter by his side. Reviewing it afterwards I felt we absolutely did the right thing, we provided just the right balance of support and privacy, the quality of communication provided by us (and here I’m referring to the whole team: me, ED consultant, nurse, and surgeon) was outstanding and I think despite working in a busy, small department we provided him with a really good death. Rather than draining me I felt this encounter refilled my tank, and particularly the reflection afterwards provided a sense of satisfaction and achievement – it has made me a better, more resilient doctor.

Breaking bad news well requires skill, time, experience, emotional intelligence and empathy. We cannot forget the tragedy of the people we’re breaking the news to, but we can also gain satisfaction from doing so well. Giving yourself permission for this satisfaction when there is so much grief involved is extremely difficult but will strengthen you and also improve the quality of communication. It’s a real chance to give a life changing gift to these families: better psychological outcomes – particularly in families of organ donors – and a more positive memory of what for most is an indescribable tragedy.

Next time you deliver bad news review your delivery afterwards. Allow yourself to feel you did a good job, and if you just watched someone else do a good job don’t be embarrassed to tell them afterwards. Preserving our psychological strength to carry out these conversations well gives so much to the families in their time of tragedy, and allows us to keep our reserves full. 

 

How can we stay resilient in difficult work times?


This piece has been circling round in my head for a bit now. I’ve been trying to think of ways to make it accessible without sounding like a self help article, yet keep the salient points in there, and remain true to the original course that it came from.



When we chose medicine as our career we didn’t choose it because we wanted a nice calm 9-5 job. We knew it would be stressful, we knew it would take over our lives, we knew there would be times it drained our psychological energy. Were we prepared for quite how much our energy would be drained? At times I don’t think so. The stress of having to be in three places at once, flip-flopping our circadian rhythm from night to day, rotating from job to job every three months, being new all the time and yet being empathic and attentive to our patients no matter how we feel inside.
Are we trained for this? Should there be sessions at medical school on building resilience?
The NHS has resilience built into it. We can cope with a few fallow years with stretched budgets, reduced investment, delay to equipment replacement, but after a while the strain starts to show. We have now had more than five fallow years. I find it immensely frustrating – a small investment or increase in budget would make our service so much better. The imposition of the new junior doctor contract was the last straw for many, crushing their remaining enthusiasm and draining their last drop of psychological energy. 
At a recent rather excellent session on building resilience we discussed strategies for remaining positive and effective in a difficult work environment. Staying positive and enjoying your job at a time when there is a complete refusal to engage by government despite the protestations of the vast majority of the medical and nursing profession is hard, but essential. At this point I’m not just referring to the junior doctors dispute but the treatment of the NHS as a whole.
How do we avoid being drained? How do we remain happy and effective when our work environment is against us?
I think first and foremost we must build and vehemently protect our social support network. Working as a part of a supportive team, having people around you who build you up, who are positive and enhance your life, and who recharge your psychological energy pot. This includes us supporting others. Staying positive, building up others, avoiding draining their psychological energy.

 
As a part of world sleep day last month, my friend and sleep expert Mike Farquar (@thefourthcraw) filled his timeline with gems on how to optimise sleep, protect your rest times and deal with the constant jet lag of shift work. A well rested person has so much more to give to others, so much more reserve for difficult days.
There is so much more here to talk about – probably worthy of a couple of more blog posts, or even a series of its own. I think my take home message from this post is that we have to stay positive and keep ourselves in the optimum condition not only for doing our job but for keeping our personal lives happy and successful. We must actively protect our time, our relationships, and our reserves.

I want to acknowledge Ruth Roberts (@execstrength) for her ideas here. Thank you! I’d also like to throw this open to others. Please post ideas in the comments section or tweet using the hashtag #NHSresilience to collate them.