Fusion stories: Tikka Masala, Bluegrass and Prehospital Critical Care

Chicken Tikka Masala was invented in Glasgow by fusing tomato soup with chicken cooked in a Tandoor oven. Bluegrass music arose in Appalachia from the fusion of Irish folk and African jazz. Prehospital critical care similarly arose from the fusion of hospital-based emergency medicine with the incident management skills of paramedicine. 

Doctors with critical care skills have their cultural locus in the hospital. As such, they see the clinical course of disease and injury and develop hard-wired reference points to interventions that sometimes play out badly over the days following admission. Protracted weaning from ventilation, empyema or persistent air leak from chest drains, neurological damage from hypoxia or hypotension during intubation to name a few. They also tend to be at the front edge of new techniques, from point-of-care ultrasound to video laryngoscopy and on to ECMO and REBOA. The same is true of new approaches to intensive management such as early inotropes in sepsis, multi-component blood transfusion and protective ventilation strategies. Some prehospital situations however can be complicated by medical staff who don’t see the big picture. I’ve been stuck literally in a hole more than once wanting to provide impractical medical care when the priority (clear to the experienced paramedic) was evacuation from a deteriorating and dangerous situation.

Paramedics with critical care skills (CCPs) conversely have their cultural locus out-of-hospital. As such they see how an incident might play out in several different ways and instinctively choose a course of action based on hard-wired reference points that balances risk versus potential gains. This may include expediting care that relies on speed to definitive intervention such as damage control surgery or delaying immediate “scoop and run” because they can better deliver the most urgent intervention on scene such as post-cardiac arrest stabilisation, relocating a badly displaced fracture, giving an antidote to tricyclic poisoning, or providing emergency sedation to an unmanageable patient. Other situations though require the longer or broader view of the physician, like sitting out intubating the critical asthmatic while the bronchodilators work, anticipating the profound bradycardia that accompanies pressors in spinal shock, or spotting digoxin toxicity driving complex arrhythmias. 

Some high acuity situations might be perfectly well managed either by two suitably skilled doctors or by two advanced practice CCPs. (Having only one skilled practitioner for a badly injured or critically ill patient who is paralysed and ventilated is clearly far from ideal). Both disciplines have similar skills to be deployed – intubation, ultrasound, surgical procedures, vascular access, ventilation. Who is better at any one skill is clearly a matter of individual experience, training and practice. But when the situation is non-standard, or where normal processes are overwhelmed as in a major incident, the best solutions arise from the cultural fusion of a well-drilled and experienced multidisciplinary team. Ideas can be blended from different places when the recipe book has a missing page or when a crucial ingredient is missing.

Arguments against multiculturalism in society in general or multidisciplinary teams in prehospital critical care often run along the same lines: societies or services must be protected from the very forces that allowed them to develop and flourish in the first place. In the case of prehospital critical care teams, professionals may be afraid of losing status or career opportunities, and the cheapest team configuration is vaunted as being the most cost-effective. Evolution and innovation however rely on access to a deep gene pool of different ideas, talents, experience and cultures in which creative DNA is regularly exchanged. As for value, the investment in sustainable, versatile, high quality prehospital care reaps real dividends in terms of avoidable death and preventable costly long-term disability for patients. 

The success of the Scottish Trauma Network has been largely built on the relationships forged between different professional groups across the chain of survival and recovery. At one end, stands the strong collegial relationships between a high-performing stand-alone CCP cadre, and the multi-disciplinary physician/practitioner critical care teams. Staff move between the two teams and are tasked by the same critical care desk in Ambulance Control. Both help the other to be better, innovation thrives, skills are shared, and jobs are scrutinised together for improvement opportunities. At the other end of the patient journey, the prehospital section of the network advocates strongly for investment and growth in the rehabilitation services, because without them the prehospital wins are dissipated. In return, the rehab teams argue that good prehospital critical care delivers them patients with the potential for a full recovery.

Planning prehospital critical care services might therefore be best done over a great Chicken Tikka Masala and with Bluegrass music playing to set the scene. The assembled multidisciplinary team can then lever all their diversity and passion to achieve the most successful evolutionary trick of all – collaboration in pursuit of a shared objective. In this case, excellent patient care.

A Wasted Weekend of Fruitful Effort

Just finished a weekend of late shifts in a busy urban emergency department. Pretty tired but worked with a good team and we got some stuff done. Felt like taxpayer got a reasonable deal paying for us to be there, especially the old folk who were part of a generation that fought to have the NHS there for them later in life when they needed help, and the patients who would otherwise have been dead or badly disabled without rapid on-site intervention.

According to some clever folk, however, we were part of a failed system that needs to be changed urgently to save the NHS. We didn’t meet our targets, and our very existence encouraged people to come to a hospital when they could be equally or better cared for at home. We are the past. In the future, we can sit in a call centre, consult by video call, organise home teams to provide treatment, and then get a private company to deliver electronic tags to the patients’ homes so that we can watch them recover remotely.

Questioning my own lived experience, I went back through my patients across the three shifts in the different areas of the department. Resuscitation first. Cardioversion, major trauma management, intubation and ventilation, inotropic support, joint reduction under sedation, transfer to theatre for immediate surgery. Some patients were obviously unwell or badly injured from the start, but a few came in through from minors as potentially low risk, with presentations such as syncope or dizziness.

Next, the Majors area. I admitted many of these patients to hospital. Severe abdominal pain requiring titrated narcotic analgesia, asthma requiring back-to-back nebulisers and a bed near an ICU, fractured hips needing pain-relieving nerve blocks then surgery, and acute cardiac conditions with a risk of malignant arrhythmias potentially needing cardioverted or angiography to prevent long term heart failure. Three patients had severe delirium requiring emergency sedation. A handful of isolated frail elderly with acute medical decompensation who were now unable to mobilise safely or attend to basic self-care needs without immediate 24hour care.

Finally, the Minors area. I sent most of these patients home. Some came in with “red flag” presentations like thunderclap headache, cardiac sounding chest pain or paracetamol overdose. Scan, blood test, home with good negative test, done. Some had injuries needing x-rays or sutures. Done and away. Some had new presentations that had resolved like GI bleeding, DVT, TIA or seizures. Basic stuff done, discharged, specialist clinic follow-up. One had a deterioration in complex neurological disease and was admitted for tertiary care. A couple were sent through to majors or resus from triage with higher acuity illness, and two were removed by police in the triage or waiting areas for violent conduct.

I suspect most patients were reasonably happy with their care, except the ones that waited ages to be seen in minors because we were short staffed and providing default care to ward patients stranded in ED due to bed block. We are told however that 66% of this effort was wasted on “inappropriate” people who don’t need to be there, and who should be treated virtually in the future to free up capacity. 

Reviewing the shifts, this is puzzling. We admitted those who needed critical care immediately, and those who had the potential to deteriorate and need defibrillated, ventilated, or invasively monitored. We investigated for potentially life changing conditions using readily available x-rays, CT scans and batteries of blood tests to allow the negatives to be safely discharged with a completed episode. Some definitive treatments were provided, all patients had the therapeutic effect of an in-person consultation, and some vulnerable patients were brought into a place of safety from precarious social circumstances.

Perhaps this is clinging on to the past and just throwing virtual sabots around. The dehumanisation of care is maybe just another part of the systemic social disconnection and downgrading of shared public spaces and services. For a patient to reap the benefits of virtual healthcare however will require living in a decent house, speaking English as a first language, and being young and educated enough to be able to make a monitored Avatar of yourself. Homeless, mental health problems, asylum seeker, elderly, no internet, illiterate, lonely? Please form a small queue for remaining hospital bed in the margins. The cost in terms of money and environment of all this innovation relative to centralised medical care is disputed. Certainly, a very large number of staff will spend a fair bit of time driving about or watching computer screens. A few private companies will make a lot of money supplying vast quantities of equipment. 

Once the transformation is complete, the patient left alone at home who collapses and triggers their remote monitor will flag up to one of the redeployed Emergency Medicine staff in the call centre. They will then try to find a critical care response to send and what remains of a real hospital bed to put them in. At least if/when they arrive at the down-sized real-world facility, they won’t be labelled as inappropriate – at least until the next innovation.

Distraction: "Closer to Home" Sings the Innovation Choir

Jimmy Carr used to have a game show where contestants performed challenges while unpleasant things were happening to them. This appears to have set the model for healthcare innovation. An NHS illustrative video shows how this will work to save the unscheduled care system.

In it, an elderly patient experiences red flag symptoms of a brain haemorrhage while baking a cake. Her concerned husband calls 999, an ambulance attends, and she is taken to A&E. Instead of being “admitted for tests and monitoring,” she is sent home to a virtual ward. Once home, she then answers a quiz on the phone and gets to test her IT skills by setting up a web-based monitoring system sent by courier, presumably while still dealing with the thunderclap headache and related symptoms. She then must make her way back to the hospital for the necessary scans at some point later. Unless that is, she collapses at home from brain haemorrhage complications, when her husband would presumably be guided to call the 0800 INTUBATE line for immediate help.

This novel approach replaces the outdated idea of using the first attendance at the Emergency Department to relieve the distressing symptoms and rapidly carry out a CT scan to exclude a potentially fatal but treatable condition.  An ED scan carried out within 6 hours means a lumbar puncture at 12 hours is not required so the patient can be rapidly discharged, and further complications avoided. 

Meanwhile on the bigger scale, hospital managers and planners get to play their own game of Distraction where the big question is on how to fix the overcrowding crisis at their front door. In this game however, the discomfort is borne by other people. Patients spend nights on ED trolleys without ready access to food and toilets, in bright lights, exposed and surrounded by noisy violent drunks. Staff burn out from witnessing their distress and the moral injury of being unable to provide the care they know is warranted. 

The answer, they reply with the confidence of evangelist preachers, is to discourage, redirect and procrastinate emergency patient care at every possible opportunity to reduce demand. “Closer to home” sings the Innovation Choir behind them. The voice of expert opinion, trying to supply the correct answer of focusing on shortening bed stays and maximising physical capacity, struggles to be heard in the background. Jimmy Carr laughs and raises an eyebrow. 

https://www.healthcareimprovementscotland.scot/publications/independent-report-finds-that-nhs-greater-glasgow-clyde-must-repair-relationships-to-improve-care/

My "Alternative to Darzi" report:

1. Act early in time critical conditions to prevent expensive disability and costs of long term care. Ensure equitable & rapid emergency access to STEMI PCI, stroke thrombolysis, prehospital critical care in trauma & cardiac arrest to stop secondary harm after primary damage. 

2. Investigate possible new cancer in days, not months to reassure most and intervene at stage 1 for those that need treatment before social and NHS costs mount up managing metastatic disease.

3. Protect ED capacity to rapidly rule out or treat NSTEMI, surgical abdomens, sub arachnoid bleeds, head injury, limb/mobility threatening fractures, complex wounds, poisoning, delirium, DKA, sepsis. Acute timely care with scanners & specialists, not fob off, redirect, and hope expensive procrastination does not lead to an adverse event and costly legal settlement.

3. Rehab the shit out of all admissions from day 1 to save money. Intensive and relentless focus on speech, mobility, ADLs, psych, diet. Maximise potential to get the patient home, looking after themselves, or even back paying taxes and caring for their dependents.

4. Prevent delays to social care. Empty out people lying about in wards losing muscle, confidence, & social networks. Pay carers properly, encourage overseas workers to come and stay, nationalise care homes. Way cheaper than blocking hospital beds, hobbling ED, & cancelling electives.

5. Support primary care as a medical home for long term care of chronic conditions with clinical continuity and regular medication review. Mental health, COPD, diabetes, frailty, arthritis, renal failure. Nip deterioration in the bud, keep them out of hospital. Clear, pre-agreed, treatment escalation plans for those approaching end of life.

6. Insist private hospitals doing the quick and easy electives compete on same field as NHS by charging for clearing up their messes and half-arsed referrals to ED. And subject them to same critical governance and scrutiny. And charge a levy for using NHS trained staff. And legislate no exclusion clauses from health insurance policies.

7. Ban all NHS meetings that last more than 1 hour, or involve more than 7 people, or recommend setting up a SLWG to report back, or use the phrase "moving forward". Remind senior NHS managers that fixing problems is better than looking for who is to blame.

Summary: Early definitive & intensive interventions in acute problems. Continuity, stability and vigilance in chronic problems. Staffing, flow and urgency in hospitals. Make costs of private care realistic to prevent parasitism on public, universal healthcare. Cut out all the bullshit meetings, directives, zombie ideas given birth on post-it notes, hobby horse re-organisations and DO THE REAL WORK.

💙 NHS. 

You're welcome.

https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england/summary-letter-from-lord-darzi-to-the-secretary-of-state-for-health-and-social-care

The Fantasy Maths of Redirection

Here’s why the potentially risky and unpopular redirection of patients away from A&E is a distracting side show from the real cause of service failure. A long thread with sums. Take a medium sized average A&E seeing 200 patients per day.

50% patients are very unwell or have high risk presentations and need a full history, examination, ECG, X-ray, scans, blood tests, and treatment. This takes approx 120 mins in total of clinical time in a cubicle. Total time = 120 x 100 = 12,000 mins per day.

50% patients need a more focused quicker assessment for less complex, lower risk problems. This takes 20 mins for those that need a test, treatment or X-ray and 10 mins for those that don’t. Assuming 50:50 split: Total time = 50 x 20 + 50 x 10 = 1,500 mins per day.

30% of the all patients (60) need admitted to hospital and wait in A&E for a ward bed occupying a cubicle space. This wait is 60 X B where B is the bed wait in minutes. This is normally 60 mins when beds are available: Total time = 3,600 mins per day.

So in our average department, we need 12,000 + 1,500 + 3,600 mins = 17,100 mins of cubicle space per day with a 1 hour bed wait and no redirection. This works out at 17,100/1440 = 12 staffed cubicles.

If all the patients (25% = 50) who need neither a full assessment nor tests are redirected at the door, we save 10 mins per patient = 500 mins (assuming redirection takes negligible time). This reduces the staffed cubicles needed to 16,600/1440 = 11.5 staffed cubicles.

If instead the average wait for a bed increases due to a doubling of admission delays to 120 mins, the bed wait becomes 60x120= 7,200 mins. We now need 20,700/1440 = 14 cubicles to avoid corridor waits or queues for assessment.

And if those bed delays further increase to average out at 4 hours, we need 60x240 extra cubicle mins which means a requirement for the ED to have 27,900/1440 = 19 staffed cubicles.

So increasing bed delays (which btw add no clinical value and put patients at real risk of harm) from 1 hr to 4 hrs means the necessary ED footprint to avoid crowding and queues increases by 7 cubicles.

Whereas, redirection of every patient not likely to require the services of an ED reduces the necessary ED footprint by less than half a cubicle. 

Currently, bed waits can exceed 10 hours. But hey, let’s look over there at a few unfortunate patients who have for a multitude of reasons ended up seeking help from an overcrowded A&E rendered too small by the maths of poor hospital flow. 

The Laryngoscope is Mightier than the Paperclip

It’s that NHS no money time again. Every new paper clip to be signed off by the chief finance officer. Hiring freeze, travel ban, recycle the teabags. These savings are a matter of familiar ritual - as much as the spending frenzy of late March. Badged as efficiency, managers flex and pump their iron fiscal will on the profligate and wasteful clinical teams who get on with business as usual. 

In addition to the “efficiency” savings, the rationing chat volume gets turned up from normal distracting background hum to persistent shrill whistling. Can’t do everything for everybody, patients need to take more responsibility for their own health, care needs to be provided closer to home. Patients however continue to thwart and dodge the various hurdles set for them by having complicated illness that doesn’t algorithm too well and gets worse when ignored, deferred or redirected.

Meanwhile lurking in the shadows ready to burn through massive piles of fivers are the lost opportunities to prevent the eye-watering cost of disability and long term care needs. Patients no longer able to feed themselves because they didn’t have their airway secured quickly after their head injury. Families giving up jobs to care for a relative with severe neurological complications due to prolonged hypotension and hypoxia post cardiac arrest. Beds blocked for months by patients with complex infected compound fractures that lead to life-changing amputations for want of  early reduction and antibiotics. 

The dividend from good emergency care preventing secondary insults and early intensive rehabilitation adds up to an awful lot of paper clips and teabags. We can’t afford not to invest in preventing harm when money is short. As the man said: "Nothing is more expensive than a lost opportunity".

The Broken Bus: a Public Service Allegory

Once upon a time a bus station in a big city had only one broken bus on an essential route into town where all the services were. It spouted toxic fumes into the cabin and had three loose wheels and a broken back door. Now and again, passengers would die in it because it would crash, they were overcome in the toxic atmosphere, or the back door jammed and they couldn’t get out and asphyxiated. The bus drivers had been saying for 10 years the vehicle would wear out if it continued to be thrashed every day. 

They repeatedly contacted their managers about the safety of continuing to drive in it with passengers at high speed. Their managers said they were just poor drivers who just needed to do fewer journeys (like they did in a town far away who liked to speak to the government). Staff often went off sick rather than drive it, and some left for jobs with Uber.

The drivers were fed up and decided to take the bus to an allegedly independent garage who said they would review it. Unfortunately, the garage didn't look at the vehicle - they just asked the managers who said it was fine. The drivers then asked the garage owner to look again properly, and he apologised and said he would do a proper mechanical inspection. Meanwhile, the managers bugged the drivers rest room and threatened disciplinary review of anyone suggesting the vehicle wasn't roadworthy. 

The managers finally offered to visit the drivers to understand their issues, despite them being very busy and important people. They explained that they have superior knowledge of driving buses and were very passenger-focused, but that they would make time to visit the bus station to show staff how much they care. The garage report on the vehicle could wait, they said: "We are all one big team that needs to respect each other, and actually fixing a bus is difficult". 

The drivers told the managers they would prefer not to meet until they had the garage report. “We believe it needs a new exhaust, a working back door and three new wheels. There is no point in meeting until it is safe to drive again. Then we can meet with you and discuss how we maintain the vehicle and expand the fleet to prevent this problem in the future.”

So the meeting was cancelled, the vehicle was fixed, and passengers arrived safely. The managers were given MBEs for services to transportation and lived happily ever after. The End.