Dr Rachel Morris ST6 Neonatal GRID Trainee

If you would like to know more about applying to be a Dreamflight doctor please contact me on rmmorris19@gmail.com or see our website at www.Dreamflight.org. and PLEASE remember to NOMINATE!

 Annabel Greenwood ST4

​The All Wales Neonatal Safeguarding meeting, hosted by the Wales Neonatal Network, was an eagerly anticipated event, particularly given it was the first of its kind in Wales to date. 
 
As Neonatologists, our exposure to safeguarding is often limited.  Let’s face it, we’re far more comfortable managing clinical problems or performing practical procedures, than dealing with safeguarding scenarios.  Unfamiliar territory brings with it an air of uncertainty. 
 
From a mental wellbeing perspective, it’s not only the babies to consider on the neonatal unit, but also the parents.  It has been well documented that adverse childhood experiences (ACEs) can affect both health and well-being later on in life, and it is therefore imperative to provide the appropriate support and guidance early-on for parents in the attempt to reduce the chance of an ACE occurring.

The All Wales Safeguarding Meeting was held in the Life Sciences Hub in Cardiff Bay, with panoramic views across the waters providing the perfect setting for thought and reflection on such a complex and emotive subject.  There was a fantastic representation from all members of the multidisciplinary team, and it was invaluable to hear people’s different experiences and perspectives on various safeguarding cases.
 
The day began with a discussion about ACEs and the concept of resilience in being able to deal with certain ACEs.  The Welsh ACE Study conducted in 2015, concluded that for every 100 adults in Wales, 47 have suffered at least one ACE during their childhood.  The prevalence of low mental well-being in adults increased with the number of ACEs suffered in childhood.  There has also been an association between ACEs and the effects on physical health and health-harming behaviours in adult life.  It is important to note that some people are affected more than others by ACEs, and this can be partly explained by a one’s level of resilience.
 
Thereafter provoked a discussion on how we, as the multidisciplinary team, can support parents on the neonatal unit, e.g. providing access to counsellors, neonatal nurses with a specialist interest in mental health, neonatal therapies, and also ideas to enhance the level of support in the community.  Certainly, food for thought…
 
It was interesting to hear the experiences from a clinical psychologist’s perspective on perinatal mental health and children’s development.  Dr Cerith Waters took us through the child development study, a longitudinal study beginning in the 1980s, and highlighted the key findings regarding the association between exposure to depression during pregnancy and a child’s long-term psychological and cognitive development.  The study findings highlighted the importance of early intervention in pregnancy to help reduce the incidence of subsequent depressive disorders in young adults.
 
A number of case presentations then followed, igniting detailed discussion signposting the safeguarding pathways and support available.
 
The afternoon session included an infant mental health perspective on preventing emotional abuse and neglect, presented by Robin Balbernie, a child psychotherapist.  This session highlighted the key difference between adult and infant mental health teams, namely that infant mental health teams help ‘get it right’ from the start, as opposed to intervening later-on in life when a person has already ‘gone off-course.’  He emphasised that the first relationships are the most important, and that traumatic events experienced early on in one’s life are preserved life-long. This relates to neuroplasticity and the concept that the earlier the maltreatment, the greater the effect on the brain.  Whilst at the same time, the earlier the intervention, the greater its effectiveness.
 
This was then followed by an interesting discussion by Dr Lizzy Nickerson about the difficulties in recognising birth injury versus non-accidental injury (NAI).  This talk really hit home the importance of clear documentation at birth and following the newborn examination, particularly in the case of a representation to hospital a few days later with suspicion of NAI.

From a personal perspective as a junior neonatal registrar, I found this day invaluable in enhancing my knowledge and confidence in safeguarding on the neonatal unit. Safeguarding is a complex and emotionally challenging area of paediatric and neonatal medicine, emphasising the importance of teaching days like these to raise awareness and ultimately improve our clinical practice. 

Guest Blog from Dr Emily Shand

Dr Tom Cromarty
Welsh Clinical Leadership Fellow, Paediatric ST5 Trainee

Having been a Leadership Fellow for at least three months now, I am beginning to appreciate some of the key traits which great leaders develop and demonstrate. The opportunity to attend leadership conferences enables me to be immersed with people enthusiastic about medical leadership. People who are passionate about improving the lives of medical staff and the patients they serve.
 
The “Leaders in Healthcare” conference was run by the Faculty of Medical Leadership and Management or “FMLM”. The FMLM aims to professionalise medical leadershipand improve patient care. Trainee membership is £84 per annum and you receive a whole lot of bang for your buck if you use all that is on offer. The conferenceconsisted of 3 days of masterclasses, keynotes and plenary sessions with a diverse set of speakers.
 

​To be honest the most reassuring reflection from the conference was that there are no ground breaking new short cuts, evidence or cheats to employing great leadership. 
https://hbr.org/2018/11/the-fundamentals-of-leadership-still-havent-changed.
 
Often with the best presentations, your practice is challenged, and usually more questions are generated than answered. Below I have put together a few small summaries of my favourite sessions over the week. I hope you enjoy them, there are also some exercises at the end to try.
 
Political Astuteness: aka “Influence in Organisations”
 
The world in which we work can seem vast, that’s if we are even given the chance to look up and have a glance for ourselves. Early on in a career, often the overwhelming thought is “I don’t do politics”. The usual pattern then follows with “Wowza, I need to know about politics” (to change things for the better) and finally “I need to tell everyone about how to master politics at work” (so we can all change things). This realisation is a like a loss of innocence. It’s easy to think you are just a sheep, but the world is complicated, and you NEED to develop political astuteness to be effective in the world.
 
Directing individuals through authority or using a badge/label to exert power is not leadership, it is management and poor management at that. Leadership on the other hand is the ability to influence individuals. Influence cannot be bought or attained through hierarchy. The internal values one holds, shape their external behaviours. Your behaviours are the markers on which you are judged by others. For this reason, influencing power can be developed by and exerted at anylevel.
 
“Does she/he do what they say?”
As an individual you decide…“Am I going to be influenced by him/her?”
 
Patterns not Problems: Working with Intractable Issues
 
Types of problems:

• Simple – seen before, solved before, can predict the outcome, minimum uncertainty.
• Complicated – break problem down to (many) simple problems, then can figure it out, e.g. hospital construction.
• Complex/wicked/intractable or “sticky” issues – e.g. people/social issues, bad culture, e.g. healthcare systems, Brexit
  • When old assumptions are challenged
  • Won’t stay solved for long
  • Too many factors/pieces – too big to think of all at once
  • Involve massive interdependencies, change effects so many areas, causes other problems to form. Any intervention in a complex system has effects that you didn’t expect
  • Non-linear effects- small change with big outcome, large change no impact.

 













Stephen Powis, National Medical Director of NHS England
 
“In uncertain times, the only known is that there will be change,
and it looks like it will be YOU doing the leading!”
 
Digital revolution: Not just AI, but intra-operability, health/medical data, wearables.
Link to the global health agenda.Genetic revolution: Need masses of space.
 
Currently leadership is seen as aposition for individualsrather than a behaviour for everyone. We must stop the unhelpful “I’m just a….” attitude and the notion of“Don’t get ahead of yourself there Dr. X, you don’t need to be doing that yet”. Leaders need to aim to regularly add value to the people around them, and everyone can do that, every day.
 
“It will never be someone like me” But think “Control your own destiny” it needs to be done by someone, why not make it you?
 
Read theBMJ Leaderfor leadership tips, research and evidence.
 
Matthew Hancock – Health Secretary England
 
The NHS needs a leadership culture change. We must stop apportioningblame but start really harnessing a culture of learning from mistakes. Anyone who says they have never made a mistake simply isn’t telling the truth. And the truth is at the heart of honest reflection, learning and moving forward. We want staff to challenge without fear and encourage complaints as these are opportunities to improve. Ideally, we want to give away the directive and hierarchical power and consequently empower all individual healthcare workers.
 
This is what we are! This is where were going! This is how were going to get there!
Ends with a challenge:
What are you going to do?
 
 
Tim Swanwick - Leadership in the Undergraduate Years
 
“Leadership is a contact sport which brings about change. This cannot be done from the comfort of a desk or department headquarters. The key to developing leadership skills is to get outside of your comfort zone, that’s when you learn the most. Seek out opportunities and go for it. Lead the way to your own future.”
 
“Management makes sure the ship is stable, Leadership sails it in the right direction.”
 
It seems like it wasn’t too long ago where communication skills were thought of as innate. If you had them, you’d be a GP, if you didn’t then you’d be a surgeon or a pathologist (I jest of course but you get the point). Thankfully, at least for the past 15 years, medical schools have recognised that everyone needs to be taught these key skills and consequentially there have been significant improvements. Communication workshops with breaking bad news and explaining diagnosis and management plans have upskilled all doctors and made a massive impact on the care delivered to patients and their families.
 
The tide is changing, leadership & management is being asked about in medical school interviews. Specific leadership skills curriculums are being introduced into universities across the country next year.
“What if every newly qualified healthcare professional graduated thinking as a leader.”
 
GMC document 2018 – “Outcomes for graduates”. 1stdomain in the curricula.

https://www.ted.com/talks/angela_lee_duckworth_grit_the_power_of_passion_and_perseverance?language=en
 
The science of Leadership & Management is not new. There are 15,000 members of the American Academy of Business who have been researching L&M for many years. The BMJ Leader could bring business school world evidence to medicine.
 
His best advice: Go and get some honest feedback, it will be perhaps the most useful gift you will receive from a colleague?!? Try asking this… “Tell me one thing that I do which is negative?” It takes a degree of bravery for you to ask and reciprocal bravery for them to answer honestly as well. He also insists that we should all have mentors. One can have multiple mentors, e.g. a leadership and speciality mentor. They offer a sounding board for example, difficult interactions with a colleague. They can guide you and order your thinking.
 
Consider the following as some of the more “formal” leadership opportunities:

​Other Resources:
NHS Improvement: Developing People Improving Care
Great project in Scotland: Project Lift: NHS Scotland https://www.projectlift.scot/
 
Diversity And Inclusion in Healthcare
 
Do you know what the 9 protected characteristics of the Equality Act 2010 are?
Do you know what “BAME” stands for?
 
This was a really interesting session recognising that even if there is diversity in the workforce or patients, these groups may still lack full inclusion or equality. Leaders need to learn how to o address these issues and respond to unconscious bias. How to hear some difficult messages, and how to respond positively. All too often issues are not confronted as “Oh this is making me feel uncomfortable” or “Of course we’re not, that can’t happen here”. We all need to be “Power aware, Identity aware and Self-aware”. The mindset we embrace in the workplace that liberates other people.
 

​Often organisations only take a stand when it gets to “Discrimination” stage, as the lower levels are largely invisible to those not affected by it. We need to upskill leaders so that everyone is aware of what is happening, the behaviour is addressed sooner, everyone has the courage and permission to call out bad behaviour. Courage is the most important of all the virtues, without courage you can’t do any of the other virtues consistently.
 
“The behaviour we walk past is the behaviour we accept”
 
Barriers to successful inclusion:

• Complex problems with discomfort talking about them.
• Denial re-enforcing the status quo easy for people to deny that it is the case in their institution – embeds the behaviour people complain about).
• The burden of calling out issues is not equally distributed across the organisation. Need to raise awareness across the whole team so that it is not the same people have to be courageous and highlight bad behaviour time and time again.
• Unsure about what to do/where to start. Be curious enough to understand.
• “It’s the silent violence that goes on”. Don’t want to say the wrong thing.
• Lack of understanding about how structural and systemic forms of inequality manifest themselves. Modern day discrimination manifests itself. Silenced, dissuaded from being themselves in the workplace, NOT name calling, etc.
• People misunderstanding how to use themselves in a leadership role to make a difference. We need to recognise that we can allbe instruments of change, and it is “how you show up” every day that can influence other people and transform the lives of those people you work with. In fact…

 
“The only person I can change is myself, how I show up might encourage others to shift their focus, their attention and their behaviour”
 
If you are reading this, you are part of the generation that can make the change!
 
Malala Youssef – Nobel Peace Prize award speech– “Let this end with us”
 
 
Richard Watson – Futurist: 
Mega Trends and Technologies2017-2050
 
It seems that Richard and many others who look to the future can only be sure on one thing, “it is UNCERTAIN and there will be many ways of doing things”.Now for someone who is highly paid for their predictions this seems like a great way of hedging your bets. He also highlighted the worrying change in society with the dominance of screen delivered information and a sedentary lifestyle. Previously children would have been told “behave or you will have to go inside!”, now it is the opposite! He described a world where devices know more about you than you do about yourself.
 
Anybody who says they know exactly what the future holds is lying. However, we spend too much time worrying about it. We NEED to spend time as communities figuring out what we want to happen, using a proactive and positive mindset. It doesn’t matter if we are wrong. We must all have a collective vision of where we want to go, build narratives around the vision and step towards it. I agree with Richards aim of…
 
“Every day waking up and trying to get better,
making things better for ourselves and others”
 
Another interesting person is Yuval Noah Harari: 21 Lessons for 21stcentury - interview
 
Professor Megan Reitz: Professor of Leadership and Dialogue
Speaking Truth to Power – Have a look for yourself here– it was an excellent 60 mins.
 
Megan delivered a fantastic session about “That moment!” The one a person decides, shall I say something or not, and educated us on the act of “Speaking up”. All the scandals in healthcare organisations of recent times have something in common. People knew bad stuff was going on, but they didn’t speak up, and this resulted in patients coming to harm.
 
One reason is the belief that it is always someone else’s responsibility and absolving oneself from responsibility. “They” aren’t speaking up, “they” need to show courage. Another issue is that often those very people who say the one time they did build up the courage and spoke out, they weren’t listened to and it made no difference. What if you experimented, what difference would it make at a collective level? Think about an occasion where you decided to say something, or not. Megan uses T.R.U.T.H to discuss the issues about these decisions.
 
TRUTH: Trust, Risk, Understanding, Titles, How-to
 
Trust: The value of your own opinion
Risk: Realizing the risks of speaking up to powerful people and the ensuing struggle
Understanding: Will I be perceived negatively, will I upset someone,“Will I belong”?
Titles: We label inherently. Depending on the context, convey levels of authority
How-to: Knowing what to say, when, how and to whom
 
Megan then describes a number of traps and behaviours we all fall into which stop us from having the conversations we know we should have!
 
Speak-Up Traps: We doubt ourselves – Imposter syndrome. Check the voice, notice when it comes in. Engage with it, am I going to listen to it this time.
 
The Blind Spot: You will not listen unless you trust the value of their opinions. Can I empathise with how risky it might feel for this person to be speaking up? What titles do I have on me to affect what kind of information this person is telling me? Individuals ALWAYS think they are better at listening than other people.
 
Listen-up traps: It’s easy to forget that no matter how lovely and approachable we seem as juniors, decades later, given some labels and titles, we are all quite scary. Make sure you don’t send“Shut up” signals and not “speak up” signals by knowing your face (and the rest of your body language signals, and environment you create).
 
Today and every day, we make choices about what to say and when to stay silent. When we really help someone else to speak up or silence them. Choices feel mundane but if you add them up together it is what defines you. How you speak up and listen up represents the values you hold and the culture in which you work. If you think about it and act accordingly, you will change habits and change cultures.
 
Some exercises and information to peruse at home in your own time!
 
Exercise 1: Personal Values
Think about your own values! What matters to you? How do you display your values at work? Much of the conflict at work results from a mis-alignment of core values.
Spend some time writing down your beliefs. What behaviours demonstrate your values? None of these have anything to do with medicine or your background/grade.
 
Exercise: Search for 50 personal values on the internet. 
Step 1: Make 3 groups of importance to you (High, Medium, Low)
Step 2: Place each of the 50 values in a group
Step 3: Take the “High” group and again split these into high, medium and low.
Step 4: Group similar values together until you have 3-5 left.
Step 5: Welcome to your values, enjoy them, be true to them, live them!
 
Check out…Harry Kramer, Values in Leadership.
 

​One moves around the grid, depending on what is being demanded of us. Who else is there? Personal circumstances? Ideally there is a sweet spot (in Green) of moving around all areas, aiming to avoid the inept/donkey.
 
How do you bring people and landscape together in your head and put it onto paper?
Stakeholder mapping, mind mapping, network mapping. 

​Another tool: Understanding people landscape map(Like Nike said… just do it)
 
Length of the line: how far they are away from you
Arrow direction: if you want them to be closer or further from you
Dotted lines: are relationships you want to develop
Small circles: /10 effort to build relationship (realistically)
Stops: how far you want to bring them closer
Wordsadd a narrative: Rich picture without words doesn’t show much
 
Update it regularly, do it for different work groups. Use it for work networks, family situations, family events. For example, see diagram below:
 

Do you know the 9 protected characteristics in the UK workplace?
Age, Disability, Gender Reassignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion or Belief, Sex, Sexual Orientation.
 
 
A reflective exercise to do at the end of any teaching session, activity or experience.
Take for example this blog (which I’ll admit has a lot crammed into it). Try and think of at least one behaviour in each of the following headings...
 
Start doing: something you don’t do but think you should actively work to do more of.
Stop doing: something you currently do but will actively try to do less of or stop doing.
Continue doing:Something you are doing already but will do more of it because it works.
 

An OOPE in Sydney, Australia.

Dr Thomas Cromarty

I have just returned from an OOPE and wanted to share my experience of living and working in Australia. After embarking on the best training scheme of them all (Paediatrics) in 2012, I worked around South Wales from ST1-5. The Welsh Paediatric Training Programme Director is keen to produce well rounded paediatricians and encouraged me take the opportunity in Westmead Children’s Emergency Department, Sydney.​

I could tell you about all the trips we went on: Visiting my dad in Canberra, Campervanning around Tasmania, watching the tennis in Melbourne, taking selfies with the quokkas on Rottnest island (Perth), surfing in Margaret River, watching the Commonwealth Games in the Gold Coast, swimming with turtles on the Great Barrier Reef and night treks in the Daintree rainforest. But that will just make you jealous and me sad, so I’ll try and give you unbiased view of my reflections on a year working there instead.

​​It would make a mockery of a blog if I didn’t start by mentioning the Work:Life balance situation! My partner and I lived 500m the beach in a place called Queenscliff near Manly. Our end of the beach was quiet, had waves most of the time and was pretty much perfect. We lived on the top floor of an apartment block which included a roof top terrace aka skin cancer zone. As an “outdoorsy type” I was in heaven. There were running, cycling and triathlon clubs, surfing beaches, SUP, yoga studios, open water swimming and even Dragon Boat racing! You name it, it was expensive, but it was available.
 
Unfortunately, I worked 40km away in the west of the city which meant that I had my old friend, traffic, to contend with on a regular basis. I worked 4 x 10 hour shifts per week in the Paeds ED, with most shifts mirroring the peak attendance times of 14:00-00:00. Despite the commute, there was no chance of me moving to other side of the world and not living by the Ocean!

• Remuneration was fantastic, I received about double my UK salary, and although cost of living was more expensive, there was still plenty to go around.
  
• Westmead Kids is a single point of entry system, meaning that the ED and CAU are combined and all referrals from the whole region come through the same door and are triaged the same way.
• The ED is the Major Trauma Centre (MTC) for the whole of New South Wales and that was one of the main reasons I initially chose this placement. Paediatric major trauma is thankfully not a common event in many places in the world, however when it occurs it needs to be managed well. There were slick procedures in place, excellent staffing of the acute areas with capable nurses and consultants on the shop floor for most hours of the day. It was a perfect environment to learn in.
• Online systems for the whole hospital; ordering imaging, bloods, “consults” and other investigations was easy. Prescribing medications appeared to be safer as the process was all electronic (as long as the weight was checked correctly). Notes are easier to read and backgrounds easier to copy and paste. It does highlight the importance of touch-type skills in the future.
• Observations recorded online allowed easy recognition of abnormal and normal vital signs (“Between the Flags”). The objective numbers empowered nurses to call for help early, and if there was no improvement to the numbers, a “Rapid” assessment was required and the on-call team to review. This system picked up acutely unwell children and alerted them to senior staff quickly before they deteriorated further. Senior clinicians were able to alter alarm criteria if appropriate, for example regular salbutamol and sinus tachycardia.
• Procedure nurses on shift from 15:00 till 23:00 enabled doctors to continue to see and make plans for patients. Of course, this came with the caveat that it was only the difficult cannulas/bloods that doctors were then asked to perform, with fewer potential veins and less practice.
• An Emergency Medical Unit (EMU), allows extra time for patients that need more observation but don’t need to be admitted, using vital ward beds. Ideal for stretching wheezers, small babies with feeding issues or minor head injuries for neurobs etc.
• Paediatric trainees rotated through the department for 3 or 6 months at a time, with many completing multiple placements at Westmead or as part of the “relief rota”. This built trusting relationships between individuals and enabled much better inter-team working. These relationships are key to providing superb multidisciplinary healthcare.
• Specific work mobile phones (1 for the acute and 1 for the non-acute sides of the department) allowed messages and pictures (with consent) to be sent to fellows and consultants both day and night. Sharing of information was therefore easy, which reduced waiting times for families and enabled faster and more accurate communication between teams.
• Regular education sessions: “PET” / Acute Care Round / Simulation / Fast Sims
  
  • Ward rounds from 08:00 were followed by some form of teaching every weekday at 08:30 – 09:00 allowing the nights team to attend if they could manage.
    
  • Daily 14:00 – 15:00 teaching - afternoon starters could also attend some sessions.
    
  • Anaesthetic days where trainees could practise managing airways and intubations.
    
• There was a 2 strike rule for cannulas for everyone at every level, with Anaesthetics generally happy to come down to assist with their USS guided skills if required.
• Clowns – Dr Smarty Pants and Dr Quack. Loved them! They visited the ED relatively frequently, keeping patients, relatives and medical staff entertained.

 

I produced a PDP of goals to achieve throughout the year, these included upgrading my USS skills as well as confidence managing paediatric trauma and minor injuries. I found this particularly useful and would encourage everyone to take some time to establish some short, medium, and long term goals for life both in and outside of work.
 
I think it is essential for all medical staff to experience working in a number of different settings. This enables them to be exposed to a number of working environments and behaviours, choosing which to adopt into their personal style, facilitating their journey to becoming a more effective clinician and leader. My year working abroad will undoubtedly be different to yours and you need to decide if it is right for you (and your significant others!) What I would say though is if you don’t try it, you’ll never know… What’s the worst that could happen?!

The start of “Hells Bells” 24 hour adventure race in Noosa, Queensland

Helicopter trip over Sydney CBD

Fair Dinkum, I had a ripper of a year out and am looking to continue that growth of skills this year as a Clinical Leadership Fellow in Cardiff and Vale, engaging junior doctors in leadership and QI development. If you want to get involved with this project, have any questions about taking a year out or just want to see some more photos please don’t hesitate to contact me at Thomas.cromarty@wales.nhs.uk.

Guest blog from Dr Nicole Parish, Clinical Psychologist, Noah’s Ark Hospital for Wales

We’re led to believe that multitasking is a good thing. That tackling several activities in one go, while thinking of many more, is a highly regarded skill essential to our professional and personal lives. But could there be advantages of not planning the next activity while you’re still doing your last; of not checking your phone while eating lunch; or of not mentally replaying things from your day while watching TV?

What if instead there was a drive to do one thing at one time? Well, that’s the concept of mindfulness: to actively focus your attention on one thing in the present moment and to do it in an accepting, non-judgmental way.

I am Nicole, a Clinical Psychologist working within the Children’s Hospital for Wales and I am keen to promote the idea of mindfulness for staff well-being. As an outsider, I can see how a career in medicine could take its toll: the multiple demands, the irregular shift patterns and dealing with difficult situations on a daily basis. I feel it is important to do all we can to change the inevitably flawed systems in which we work in and, until then, support staff to manage it. Rather than just expecting them to cope.

Our working lives can make our already busy minds even more frantic.  We’ll go over things that have happened; thinking about how things could have or should have gone. Equally, we daydream about what’s to come; practicing conversations in our head or imagining the worst case scenario. In recognising this, mindfulness first asks us to slow down the mental chitter chatter. To notice when your mind is going off on a tangent and to bring it back to the here-and-now.
Then there’s the judgments we make. The continual and automatic criticisms we have about anything and everything. That sound is irritating, that person is really frustrating or I’m so stupid I shouldn’t have done that! This is why the second concept of mindfulness asks us to be open to all experiences in a non-judgmentally. Imagine two people are caught in a downpour of rain. One is furious, wishing they’d checked the weather forecast and worrying that they’ll get a cold. Whereas the other notices the pressure of the rain droplets on their shoulders and the feeling of cold water on their hands. Both of them will get just as wet, but their emotional experiences of the storm are going to be very different.

Having said that, mindfulness isn’t a miracle cure that’s going to make all your stress disappear. But focusing on only one thing may help you to feel more settled, even if just for a moment. Perhaps doing less at once could help you to tackle more? And taking the time to tune into how you are feeling may motivate you to make beneficial changes. At work you’re expected to wash your hands between seeing patients, and perhaps there is a way to think about refreshing you mind in a similar way?

If you’re interested in finding out more, the books ‘Mindfulness: Finding peace in a frantic world’ by Mark Williams and Danny Penman, and ‘Wherever You Go, There You Are’ by Jon Kabat-Zinn are a good place to start. Plus many health boards in Wales offer mindfulness initiatives for staff. For example, I deliver drop-in mindfulness sessions every fortnight within Cardiff and Vale UHB.  There are also free courses lead by Academi Wales, such as ‘An Introduction to Mindfulness’ and their 3-day retreat style ‘Explore and Walk’, which I can say first hand is brilliant.​Want to start smaller? You can make tweaks to your routine to be more mindful, the trick is finding something that works for you. My sister, for example, is a fan of listening to an app on her phone for about 5-10 minutes a day (well, on the days she remembers and that’s fine!). If you’d like the structure of a guided meditation, and could benefit from taking yourself away for a short period of time, some good ones to try are Headspace (free to download, with an optional subscription), Buddhify (initial fee for the app,  then free to use) and Smiling Mind (free to download and free to use). 

Rebecca Broomfield

13th-15th November, Southport Theatre and Convention Centre

Once again I was privileged to attend the Association for Simulated Practice in Healthcare annual conference. The train journey to get here was epic but the conference was def. worth the travelling. The conference started with a Tuesday Evening Keynote after a day of workshops. An inspiring first session from Professor Tim Draycott. He spoke about simulation giving teams a chance to 'Have another go'. Team training and teams who train together the communicate well and share leadership. But he demonstrated many examples where teams training together did not improve outcomes. So therefore what is it about a team which makes them more effective? Professor Draycott suggested that teams who did this stated the emergency earlier, the amount of directed commands was higher and they communicated using an SBAR model (Situation, Background, Assessment, Recommendation)  In teams that were training together but not seeing improvement in their outcomes he suggests looking further and ensuring that the equipment used is appropriate and that the simulations are standardised, like a recipe. He asks whether as we move forward we should be looking at simulation and evaluating it as we do pharmacological drugs - can we make it a qualy? This would engage and influence the policy makers. Could we offer insurance discounts to hospitals who regularly participate in team simulation and show that this has increased patient safety. We need to give simulation a value. He also suggested that simulation could be use to understand problems and help make the right way the easiest way. Therefore identifying ways which the system needs to change by running simulations. It is more than just knowledge transfer.

Day 2 began with one of the most inspiration speakers I have seen at a conference. Dr Kimberley Stone From Seattle Children's hospital spoke about using simulation to test out the design of a new children's hospital. They got the designers to mock up a card board version of areas such as the research room in the emergency department and the kitchen so they could run through how the rooms flowed and worked. When they found significant flaws in the design of the resus room they were able to redesign it and make it fit how they wanted it to work, all using simulation. Once the bricks were laid and the hospital was ready to open the simulated 'a day in the life of …. ward' before a patient stepped foot in the door. They were able to identify latent threats and patient safety issues and correct them without any chance for patients to come to harm.

This offered me a completely different view of simulation and one which I had not thought of using simulation for but when you look at it, it makes complete sense. If we can do practise runs in the hospital before it's built we ensure that equipment is where we need it to be and patient flow is optimised. If we then SIM each area before it is used we can identify all the latent threats and eliminate them before they become close to making it into patient care. This use for simulation looks fantastic and in the future this should become the norm.

Breakout sessions then commenced with a variety of talks on exciting projects which are happening around the country. I was particularly interested in Doreen Stockdale's presentation on running a 'Dragons Den' type competition for midwifery students to design an app which introduces the students to simulation teaching and how it works. It is often forgotten when you have been doing simulation for a while that to others it is an alien teaching form and they don't know how to do it. The app is in the process of being made and has 3 area's - Know yourself, know others and Get to know the story. I'm looking forward to seeing it finished and whether we could use it with our undergraduate students or nursing colleagues as an introduction to simulation.

The next keynote was delivered by Professor Nick Sevdalis He spoke about moving simulation from looking at Efficacy (can I work?) to Effectiveness (Does it work?) Looking a scaling up simulation training programs and how we can make it work. 

Followed by more breakout sessions. The most interesting session I attended focused on developing non technical skills recognition for junior doctors through simulation teaching. This involved designing a 'Bingo' type card for simulation observers to focus on different human factors while the simulation session was going on rather than be passive observers. This helps in developing the knowledge of the junior doctors in human factors.

The final keynote speaker on day 2 was Paul Gowen's who is the Lead consultant paramedic for the Scottish Ambulance service. He demonstrated the fantastic work which the Scottish Ambulance service has been doing for out of hospital cardiac arrests and was a very dynamic speaker, I would recommend watching his talk on catch up for a reminder about why we are all focusing on simulation to improve patient outcomes.

After a meeting of the Paediatric special interest group was done it was onto the conference dinner. Photo's of this will not be shared but I loved the addition of a mini conference photo booth!

Day 3 started with 2 keynote speeches. The first delivered by Dr Neil Ralph @DrNRalph from Health Education England who shared the notion that we should be investing in the people who deliver the simualtions and focusing more on faculty development as well as working with e-LfH to offer e-learning around simulation. Followed by Professor Bob Stone who tooke the whole room into a world of virtual reality being utilised in the armed forces and how this can be applied to healthcare. He focused very much on 'Humans first, technology second' Mixed reality in healthcare is not yet fit for purpose but its developing fast and new opportunities are emerging. plus the simulation for evacuation of casualties on the helicopter looked absolutely fantastic. His keynote offered us a taste of what is yet to come, and it could make simulation even more exciting.

I presented in the next breakout session the falls project detailed below. After lunch their were further breakout sessions to see what everybody else was doing within simulation around the country and learn about the introduction to the STEP program which ASPiH has developed to aid with the development of simulation technicians.  

The closing keynote was delivered by Bryn Baxendale. Who spoke about the development of health teams.

I was lucky enough to get the opportunity to present some of the work we have been doing in Cardiff and Vale within the medical education team in simulation.

Within Cardiff and Vale we have reorganised the way we have been creating and structuring our simulation courses. We have been making these more mutli-disciplinary and therefore focusing on team work within the NHS. We know that increasing team work increases productivity and improves patient safety. 
 We have also been evaluating our simulation more effectively and have been able to show statistically significant increases in confidence and knowledge following attendance at a simulation course. We are creating simulation courses around significant targets for the trust such as the reduction of falls. I was lucky to present orally a project we did with the Trauma and Orthopaedic department. We created a patient story simulation from admission to post theatre in order to improve the confidence of the Foundation Doctors with patient management. This has been a very successful course which significantly improved the confidence of the trainees who have been through it.

The second oral presentation I gave was on the Falls project. We are keen to develop simulation around significant patient safety issues and falls prevention and management has been highlighted as one of these. We have been working with a ward in our hospital and lead nurses have been trained in teaching simulation and are now delivering it to their teams. Again this project has been very successful.  

The two poster presentations are below and focus on a further 2 simulation course which are available. I was grateful to get the opportunity to present the fantastic work we have been doing in Cardiff and Vale to a wide audience.

In summary, if you have any interest in simulation I would absolutely recommend that you put the ASPiH conference in you diary to attend, next year is in Belfast. The keynote speeches from this year can be found at:  https://www.youtube.com/playlist?list=PLzm6Ad9XIwxksSlhE9BK4IQY2kOpKvxUJ

Thank you to the ASPiH team for giving me the opportunity to present our work and to Cardiff and Vale for enabling me to attend this fantastic conference which has given me lots of exciting ideas.

For more information:
Last years blog can be found here: https://www.wrenpaediatrics.com/blog/its-all-about-simulation
ASPiH website: http://aspih.org.uk/
Follow on twitter: @ASPiHUK
Conference website: http://www.aspihconference.co.uk/

20th November 2018

Dr Chris Course

The 32nd Annual Symposium for Cystic Fibrosis in Adults and Children took place at the Royal Society of Medicine in London on 20th November 2018. It had been organised by Professor Iolo Doull from the Department of Paediatric Respiratory Medicine and Cystic Fibrosis at the Children’s Hospital for Wales, Cardiff, and aimed to serve as an update for hot topics and emerging trends in the care of cystic fibrosis over the past 12 months. This was my second visit to the Royal Society of Medicine, and again it didn’t disappoint. It is a great venue for any meeting, and always provides excellent conference facilities and service. The RSM put on a great variety of meetings, and there is generally something for everyone, no matter what your area of clinical interest. Many of the meetings are either free or very reasonably priced.

The 32nd Symposium for CF started with a talk from Dr N ick Simmonds from the Royal Brompton about some of the diagnostic challenges emerging in the world of CF. With increasing understanding of CFTR gene variations and mutations, there is an increasing awareness of variable clinical phenotype and disease penetrance. There appears to be an increasing acceptance of a range of CF-related disease, and single-organ disease (e.g. pancreatic dysfunction with normal respiratory health) is being seen in some of the more variable genotypes in some patients. The importance of clinical correlation with genotype was highlighted, as well as the importance of functional assessment of CFTR in diagnostics. The traditional importance of sweat chloride was stressed, and a discussion was had around the emerging use of nasal potential difference calculations in functional assessment of CFTR was discussed.

This was followed by a presentation from Dr Julian Forton, Consultant in Paediatric Respiratory Medicine, Cardiff on how best to diagnose respiratory infection in children. This focussed on the successful completion of the CF-SpIT trial, led by Dr Forton (and paper available here: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30171-1/fulltext) which found that induced sputum samples were as effective as two-lobe broncheo-alveolar lavage samples (currently the gold standard test) at assessing the pathogens present in the lower airways, but were easier to obtain and better tolerated, avoiding need for general anaesthetic. There was also a suggestion that induced sputum may be superior at assessing the bacteria present in the larger airways, which can be symptomatic in children with signs of bronchitis (wet cough). The paper is a really good read, published in the Lancet, and great to see such influential research being undertaken locally in Wales. After speaking with Dr Forton, the findings of CF-SpIT are starting to change practice internationally, especially in Australia, where routine bronchoscopy (not just for symptomatic children) is a much more common undertaking.

The morning was rounded off with presentations from Dr Kris de Boeck, Leuven University, Belgium on the challenges on investigating the clinical efficacy of newer disease modulating CF drugs (such as Ivacaftor) in children with rare genotypes, and Professor Martin Walshaw
who chaired the NICE CF guideline (https://www.nice.org.uk/guidance/ng78). This provided an interesting contrast between the emerging advice on the challenges of investigating the treatment of rare genotypes with newer therapies, and the role of well-established management in cystic fibrosis and how to recommend best practice in a dynamic and changing treatment landscape.
Following lunch, there was a discussion from Professor Andrew Jones of the Manchester Adult CF centre on the complexities of which pathogens we should worry about (in short, we all still worry about pseudomonas, but with newer culture techniques, there are isolates emerging, such as achromobacter, ralstonia, and anaerobes which may or may not be associated with accelerated decline in lung function) and the challenges of extrapolating in vitro models in in vivo clinical situations. This was followed by a presentation from Professor Jane Davies, Royal Brompton Hospital, on the new and emerging therapies in CF. The future at present seems to be the CF modulating drugs, such as Ivacaftor, which improve the function of dysfunctional CFTR, and the potential for combination therapies which improve CFTR production and expression. The main challenges with these drugs still seem to be their immense cost, and correlating this with affordable clinical benefit. The ongoing story of gene therapies was also briefly touched upon, and although initial trials and mechanisms have had suboptimal results, newer trials and modalities are being developed and funded.

After a coffee break, the fellow presentations began. This was an opportunity for fellows and trainees to present interesting cases and discussion points to the meeting (and where I had the opportunity to discuss a case and the potential ethical implications for newborn screening). Despite the excellent calibre of the presentations that had come before, and their high academic rigour, the audience were kind and supportive for the trainee presentations, and I wasn’t faced with any overly challenging questions!

In summary, the 32nd Annual CF Symposium was a thoroughly enjoyable meeting, and relevant to anyone with an interest in respiratory health in paediatrics. It also provided a useful insight into the transition for these children into adult services and how the focus of management can change with the move to adult CF teams. It was also a valuable opportunity to undertake a bit of CV building with a case presentation (at present anyone who presents at the CF symposium is also invited to submit a review article on the subject for Paediatric Respiratory Reviews). Professor Doull is organising the 33rd Symposium in 2019 also, so keep a look out on the RSM website for further details.

Dr Annabel Greenwood

The SRC was established by the Kaiser Permanente Health Group in Northern California, and has reduced antibiotic use in babies by almost 50%.

It is a tool for calculating the risk of early-onset neonatal sepsis (EONS) in babies ³ 34/40 gestation.  It uses maternal risk factors together with the clinical presentation of the baby to calculate a probability of EONS per 1000 babies. 

The incidence of EONS is 0.5-0.9/1000 live births in babies ³34/40 gestation, with a 3.5% incidence of mortality.  Current guidelines for EONS are not sensitive or specific e.g. the definition of chorioamnionitis can vary, diagnostic tests have poor predictive value for EONS, and 40-50% of cases are not captured by current screening tools.  Furthermore, current guidelines do not take into account the clinical examination of the baby.

We have a duty as clinicians to improve antibiotic stewardship, avoid unnecessary investigations, and shorten duration of stay in hospital.

An initial probability of EONS is calculated based on the population incidence together with risk factors for sepsis including; gestational age, highest maternal antepartum temperature, GBS carriage status, duration of rupture of membranes, and the nature and timing of intrapartum antibiotic administration.  The baseline risk is then modified based on the infant’s clinical examination

The calculator is not currently in use in neonatal units across Wales.  However, following extensive discussion at the Wales Neonatal Network Audit & QI day, the provisional aim is for implementation early next year. 

It has already been implemented in some neonatal units across England (Plymouth, Exeter, Bath, Southampton, Oxford), with a reported 40-70% reduction in antibiotic use (depending on the centre

On reflection, after listening to the discussions at the Wales Neonatal Network Audit & QI day and exploring the topic further, I feel the implementation of a sepsis risk calculator on the neonatal and postnatal units is a positive move towards improving our antibiotic stewardship, protecting babies against unnecessary investigations, whilst at the same time easing the workload of the medical team by reducing unnecessary procedures.  However, let’s not forget that neither the SRC or current guidelines will pick up unwell babies at birth…There is of course no substitute for clinical acumen!