As part of my Master’s (MA) in Music Therapy and my training to become an HCPC-registered qualified Music Therapist (one of the allied health professions), I am fast approaching the end of my final placement, in a regional tertiary-level Neonatal Intensive Care Unit (NICU), which consists of an intensive care unit (ITU), a high-dependency unit (HDU), a low-dependency unit (LDU) and a nursery. Part of the requirements for our final placement, which forms most of our Advanced Professional Practice module, was that we had to set up a new music therapy service somewhere which had never had it before (one day per week for around 24 weeks). We could choose any client group or setting, and I was drawn to working with neonates ever since reading an article (scroll to see some reading recommendations!)by chance during the first year of this three-year part-time MA course. I was absolutely thrilled when the Senior Nurse emailed me back within minutes to say they’d love to have me on board!
I did lots of preliminary reading around music therapy in the NICU and observed a qualified music therapist working in a different regional NICU prior to commencing my placement, so I had a pretty good idea of what to expect. As with all our placements, this involved six weeks’ observations at the start, before commencing our own clinical work. Our placements are very varied, with my first-year placement having been in a Special Educational Needs (SEN) school working with a child with autism and my second-year placement in a private psychiatric hospital working with in-patient adults with acute mental health issues (and some with complex mental health issues, e.g. chronic schizophrenia and dementia co-morbidly). This sets us up for our future work, where the client groups could be incredibly varied (from pre-birth to end of life, and everything in between).
The thing about music therapy is that you usually need a wide variety of musical instruments for different circumstances. Because we often work ‘in the moment’, you just don’t know when you may need something in particular, so it’s better to have it with you than not to. Because of this, I start my day by loading myself up like a Buckaroo – one more stringed instrument and my arm might fall off! Neonatal music therapy sessions can look quite different depending on the patient you’re working with and are adjusted to what that particular baby/parent needs at that moment in time, keeping in line with their broader clinical goals. For example, when working with a term baby who was quite aware of their surroundings and in a quiet-alert state, I used musical instruments with more of a sensory impact to encourage visual tracking (e.g. the shiny, reflective tambourine, the colourful rattle or the colourful wave drum – see photo). Of course, these instruments all work on auditory stimulation, but with the added benefit of visual stimulation and tactile stimulation if the baby swipes or grabs one of these instruments. I purposely selected rattles which would be easy for tiny fingers to grip, or instruments which don’t take much physical effort to make a sound, be that with their hand, foot, arm or leg. I was careful to ensure that all of my instruments could be easily wiped clean and sterilised after working with each patient, to reduce the risk of infection.
Before beginning each music therapy session, I check with the baby’s nurse (and the parent, when they’re present) if it’s okay for me to work with the baby at that time, or whether they’d rather I came back later that day or the following week. It’s important to check that it’s suitable timing, and to be able to be flexible if not. Checking what state the baby is in (whether they are fairly alert, irritable or sleeping) is also important, and determines whether or not I work with them at that moment and, if so, which instruments I would use for that session. Different instruments would be used for different states and clinical goals, and also for different aged babies.
For babies born at very early gestational ages (e.g. 25 weeks), if they’re not many weeks old yet I tend not to work with them. Their mother’s voice will be the best and safest thing for them to listen to, whether that is through talking, humming or singing quietly. It’s crucial not to over-stimulate very young babies, as they need to adjust to the world first, which takes time. The sensory input from bright lights, noises around the ward, smells and touch can be too over-stimulating if they all occur simultaneously. It can calm them just hearing Mum’s voice (and indeed her heartbeat), whilst feeling the vibrations of her voice and heartbeat during skin-to-skin time. With this aged baby, I would only offer emotional support to the parents, and provide suggestions of how they could use humming/gentle lullaby singing, or even just reading or talking to their baby to support their wellbeing and development at that time, being sure to let parents know to watch out for signs of over-stimulation in their baby, explaining what these might be.
For babies born at gestational ages such as 34 weeks, I might work with them while their parent is holding them. In this scenario, I would use gentle (and very simple) guitar playing with just two chords, often accompanying improvised quiet singing (e.g. singing “Jacob, Jacob, how are you today?” [don’t worry – no actual patients’ names have been used in this example!]). I try to encourage parents to sing or hum along quietly, but often find that they are perhaps too embarrassed or self-conscious to do so on the ward, which I can completely understand. It’s not the same as being at home and having your own space, with no-one else watching or listening to your every move while you try to get to know your baby. Research has shown the importance of using the mother’s own voice, as this is what the baby will respond to best. The familiar sounds from being in utero (the whooshing of the amniotic fluid, the strong pulse of the mother’s heartbeat and the muffled sounds of the mother’s own voice, as well as those of people she sees regularly – so often the father’s voice is also recognisable to the baby) create a feeling of security for the baby as it tries to adjust to its new surroundings, so re-creating this in an informed and cautious way whilst watching for any signs of over-stimulation is important. During the music therapy session, I’m constantly looking out for any signs of over-stimulation (there are many!) and checking the baby’s monitor for their heart rate, oxygen saturation levels and respiratory rate, which further helps me to assess their mood and current state. I also check the sound levels of my musical interaction via a decibel-monitoring device.
With a more relaxed baby comes development, the ability to sleep and feed better and better emotional wellbeing, which is crucial for the often-traumatic environment they now find themselves in. The gato box (see photo – the two-tone wood block) is used to gently re-create sounds of the mother’s heartbeat, and with this you can help the baby to entrain their own heartbeat to a slower pulse, inducing relaxation and often sleep. Using the wave drum (see photo – the oceanic disc, complete with cartoon octopus!) very slowly and quietly (this can take a bit of mastering in itself!) can re-create sounds of the amniotic fluid whooshing around, also helping to calm the baby, reminding them of a time where they felt safe, secure and contained. The music has the power to ‘hold’ them when they are not being physically held, which is also a really effective way of helping them to feel safer. The predictable characteristics of the music, when used in an informed and careful clinical way by a trained music therapist, are purposefully used to help the baby feel more relaxed. When there is a predictableconstant for a period of time (the non-alerting style of the music used), the baby is less likely to become startled by the unpredictablesounds of bins closing, taps running, monitors beeping, doors closing and telephones ringing etc., as they have that predictable sound (the music) to tune into, which provides a sense of security. It’s also important for my sessions to be quite short – often 10 minutes is plenty. I observe for any signs of over-stimulation and bring the session to a close sooner if this occurs.
For term babies who are quite alert and aware of their surroundings, perhaps having been on the unit for a while and becoming increasingly bored by the blank white ceiling tiles above them, I work with them in order to increase neuro-development, where sensory stimulation is key. I would most likely use the reflective tambourine (see photo), the easy-grip rattle (see photo) and the wave drum, as well as my guitar and voice. Simple nursery rhymes with lots of repetition can help with early language development. The rattle, wave drum and tambourine are good for visual tracking, and any of these can be used to encourage them to move their arms and legs more, building up their physical development as they reach out to touch them. Music and sounds used can also encourage a baby who usually only looks to one side to explore the other side too, which can be good for their physical development. When the baby touches one of the instruments, it can also teach them about cause and effect, as they learn that when they touch it, it makes that sound. It can also help babies to learn the (unwritten) ‘rules’ of conversation – they make a sound, then I make a sound, then it’s their turn again, then mine, and so on. This can also provide them with a sense of security – the anticipation of knowing whether they will get their turn again, consistently having those needs successfully met, builds trust and a secure attachment, which is important for their future development, and can last long into adulthood.
It can be a bit of a balancing act at times, as I have sometimes worked with term babies who have been on the unit for quite some time who need sensory stimulation and a more lively session, yet they’ve been on the same ward as a baby who is only 28 weeks (gestational age) (e.g. in ITU). In this case, I factor in the rest of the babies on that ward, whilst trying to tailor the sessions to the individual baby I’m working with, so ensuring I’m quiet and perhaps sticking more to guitar and singing simple nursery rhymes, or improvised observational singing based on what the baby is doing, whilst slowly moving the rattle from left to right for the baby to track it visually. I often leave them a small square cut from some thin emergency blanket material (bought especially for this purpose) to play with (supervised!) on the days I’m not there – it makes a fascinating crinkly sound and is very cheap, as toys come! After each session I sanitise the musical instruments, then have to negotiate the notes… who knew it could be such a mammoth task adding a new continuation sheet half-way through a patient’s file?!
I attend the MDT meeting when possible, where most of the patients are discussed. This helps me to be more informed about the family situation of the babies (including any psycho-social issues), and also helps me to prioritise who to work with (babies andparents). A big part of my clinical work on the NICU, which people may not initially think of, is talking to (and, more importantly, listeningto) parents and providing much-needed emotional support to them. I also ran a music therapy support group for parents, using relaxation techniques and providing a confidential space for them to meet other parents and explore their experiences on the NICU, using music to help in the process. Parents can be experiencing trauma in the NICU, so it’s vital to provide that emotional support, which can be invaluable for helping them cope. Some parents don’t necessarily have much of a support network around them in the form of friends and family, so it’s important for them to have someone to talk to.
We have regular confidential clinical supervision and peer supervision, as well as clinical seminars in university. This helps us to think about the work in different ways, which ensures it remains patient-focussed and helps to achieve clinical goals. Reflective practice also plays a big part in our work as music therapists. If you’d like to get more of an idea of how music therapy sessions look in NICU work, you can watch these two short videos on YouTube (though they’re from America, so it’s not exactly the same):
Loewy, J., Stewart, K., Dassler, A., Telsey, A. and Homel, P. (2013) The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics. 131 (5), pp. 902-918.
Loewy, J. (2011) Music therapy for hospitalized infants and their parents. In: Edwards, J., ed. (2011) Music Therapy and Parent-Infant Bonding. Oxford: Oxford University Press, pp. 179-190.
Shoemark, H., Hanson-Abromeit, D. and Stewart, L., (2015) Constructing optimal experience for the hospitalized newborn through neuro-based music therapy. Frontiers in Human Neuroscience. 9: 487.
Dr Tom Cromarty
The term “Burnout” has become somewhat of a dirty word in the healthcare lexicon over the last few years. The insinuation that healthcare staff have somehow failed to build enough resilience or resourcefulness to manage the stressors of life on the front-line. The concept of “front-line” comes from war battlefields and it’s no co-incidence that this metaphor is used in healthcare. Soldiers get diagnosed with PTSD, whilst healthcare professionals suffer burnout. Both of these have at their core the issue of “Moral injury”.
If doctors were “in it for the money” then I’m pretty sure they would be astute enough to pursue another line of work. Caring for patients and their families is a vocation for most doctors, or at least it started off that way at some point in the “life choices” decision making process. However, when doctors are not able to deliver the high standards of care they intended for a variety of reasons, this takes a toll on personal wellbeing.
The symptoms of burnout are really a “signal” of a healthcare system that is failing to look after its assets.
If we want compassionate, engaged and highly skilled doctors leading the charge on the frontline then we need to provide the working environment to facilitate it. This starts with senior leadership recognising that >50% of doctors are experiencing these symptoms and they “Cannot give what they don’t have”! Many organisations now recognise the urgency of the situation and are starting to offer support. However, there are a number of skills which we can develop as individuals to equip us for “combat in the healthcare battlefield”.
I have looked up to Dr Mark Stacey for a number of years. An obstetric anaesthetist and human factors expert, he has put together a “Bakers Dozen” of skills. Written as a prescription to yourself, these can all be practiced and developed, in our quest for becoming “Anti-Fragile” (the opposite of fragile funnily enough). I have been lucky enough to hear this talk a couple of times, taking new learning points from it on each occasion. I would highly recommend contacting Mark.Stacey2@wales.nhs.ukand see the talk in person, but in the meantime here is a short summary of 'The Baker’s Dozen' by the legend himself;
1. Problems: challenge or threat?
Do you view your problems as a challenge or a threat? From a practical (and physiological) point of view it is more useful to frame problems as a challenge (problem solving mode) versus a threat (fight/flight mode). This also means reflecting on your self-talk about life eg “life is unfair”, sadly we know that, we see proof of it on a daily basis.
2. Develop optimism skills even if you are a pessimist
Having started out researching ‘learned helplessness’ (something many in the NHS will be familiar with, especially our patients), Marty Seligman has become a top optimism guru. His PERMA model (Positive Emotion, Engagement, Relationships, Meaning, Achievement) is helpful. I have also found the ‘Losada principle’ very useful - three nice things to balance/overcome one negative (unless of course if you’re in a long term relationship....).
The PERMA Model: Your Scientific Theory of HappinessAlso, have your own mission statement and rehearse it daily. Mine is “today I am going to do the best I can for my family and the people I care for”.
3. Keep a gratitude diary
What 3 things have you done well in the last 24 hours? I usually think about these on the way home from work, which sets me up to start the evening in a positive manner. How many of you when you get home complain to your partner? Flip it round – say or do something positive.
4. Do physical exercise (every day)
Do not underestimate the benefits of regular physical exercise. Lack of time is an often used excuse, but do you have time not to exercise when you look at the range of benefits (decreasing risk of Alzheimer’s, improving mood, improved sleep and many others)? The 7 minutes exercise app is a great way of moving all your body parts without taking up too much of your time.
Probably the most useful skill I have learnt in the last 25 years – it has a whole range of benefits; improved concentration, focus and sleep. If you don’t do some form of meditation you are spending less time on your mental health than you are cleaning your teeth! The simplest meditation technique I have found is the four count breath technique also called box breathing. It only takes a minute – breathe in for a count of 4, hold for 4, out for 4, hold for 4 – do 4 times – perform when you feel that acute pressure coming on and practice every day – teach it to everybody! (Even the Navy Seals are taught it!)
6. Become a stress management expert
Imagine a bucket, while at work fill it with the stressors of the day, at the end of your shift find a trigger (for me it is unlocking my bike) to empty the bucket. Now you are going home with an empty bucket ready to be filled with the stressors of home. Set a second ‘empty bucket’ trigger (like brushing your teeth before bed) to set you up for the next day and of course...
“Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory, makes you more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and flu. It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious. Are you interested?” (see number 7)
The above quote is from Matthew Walker’s recent book and if that hasn’t convinced you then I’m not sure that I will. Sleep – ignore it at your peril, it is possibly the most important performance enhancing agent available to you.
8. Ask for Help
Never be afraid to do this whether you are a senior consultant or newly appointed trainee.
9. Deal with aggression
Learning assertive skills is worth the effort particularly as there will always be conflict in our jobs.
Learning is a fantastic skill that does not just teach us the skill – it also teaches us about learning – in particular how, as an expert, it is difficult to understand why the novice is struggling to learn the skill.
11. Make better decisions
You could read the enjoyable and academic “Thinking Fast and Slow” by Daniel Kahneman or more readable “Decisive” by Chip and Dan Heath that teaches the WRAP model. In particular note the prepare for failure – we can do everything right in our job but bad things will still happen.
12. Avoid HALT in you and the people you work with
Are you Hungry, Angry, Late or Tired? Avoid these factors in yourself and look out for them in your co-workers/friends/partners/ children. They will look out for HALT in you. The HALTcampaign, lead by Michael Farquhar and Guy’s hospital, is a model worth following.
As you work through your day see how many people you can make smile.
…..And there you have it.
These are all skills! And as such they will all get better after practice and less easy when neglected. Just get started and have a go at two or three of them. I have found the gratitude diary and sleep (earlier bed times) particularly useful in recent weeks and have seen benefits in my overall wellbeing.
Mark reminded us that if you never meditate, you are spending more time cleaning your teeth than on your mental health. Some people say “We don’t have time for any of this” but the truth is “We don’t have time to neglect it”. If you want to be the compassionate, healthy, high performing doctor you always dreamt of, the remember “You can’t give what you don’t have!”
Baker’s Dozen of Mental Toughness. Your stress management and resilience toolkit
The Happy MD – Dr Dike Drummond
Mission Statement: Revolutionize the quality of healthcare by improving the health, happiness, humanity and effectiveness of the people providing patient care.
Physician Burnout Symptoms
ZDoggMD – Moral Injury
Reading List from Mark Stacey:
Human factors and resilience
Mastering Resilience in Oncology: Learn to Thrive in the Face of Burnout. Fay J. Hlubocky, PhD, MA. Miko Rose, MD, and Ronald M. Epstein, MD
Practical Human Factor training
Martin and Elaine Bromiley – “How mistakes can save lives”
Decision making and brain training!
Brain rules: John Medina
The Decisive moment: Jonah Lehrer
Decisive: Chip and Dan Heath
Three books: three slightly different takes on human error
Safety at the Sharp end: Rhona Flin
Field guide to understanding Human error:Sydney Dekker
Why hospitals should fly-much lighter than the above: Nance J.
Mind management recommendations:
The Chimp Paradox: Steve Peters (it works for the Sky cycling team)
Search inside yourself: Chade Meng Tan (it works for google!)
10 % happier - Dan Harris- true life story with loads of practical advice-advice-done be put off by the title!
26th March 2019, Cardiff
Dr Annabel Greenwood ST4
I am currently in the process of implementing a mentorship programme on the Neonatal Unit at UHW. As a trainee, it’s hard not to feel overwhelmed and at times, emotionally drained by the demands and expectations of our training. Our wellbeing and a positive mindset are paramount in ensuring we can optimise our potential, but how can this be achieved without an appropriate support network in place?
Last month, I was fortunate enough to attend the RCPCH Mentoring Skills Workshop in Cardiff to learn more about mentorship and the key principles involved. This was a fantastic one-day workshop lead by Matt Driver and Sandra Grealy, who have a wealth of experience in coaching and leadership. I feel passionately that mentorship is an invaluable process for both the mentor and the mentee, and would like to use this platform to share with you some of the key concepts involved…
So what is mentoring?
Mentoring is the process of supporting and guiding a mentee in the development of their own ideas and agenda. The mentor is usually a more experienced professional who aims to help nurture the potential of the mentee.
The Situational Model
The relationship between a mentor and mentee relies on the right balance between ‘push’ and ‘pull.’
This balance helps us understand the differences between coaching, mentoring, directing, and a more hands-off approach. Depending on the situation and the needs of the person, the balance between ‘push’ and ‘pull’ will need to be adjusted accordingly;
Coaching: The agenda is set by the coach rather than the subject. ‘Pull’ behaviours outweigh ‘push’ in this case.
Directive: The agenda is set by the ‘director.’ It is an important approach where the subject needs to have information. ‘Push’ behaviour outweighs ‘pull.’
Hands-off: The subject is encouraged to do things for themselves, without ‘push’ or ‘pull.’
So, what are the key core skills to be an effective mentor?
What about advice?
Let’s face it, if someone comes to you with a problem, it’s all too easy to jump-in with our own opinion or advice, often backed up by personal experiences.
However, this approach is not useful in the case of mentoring, as it discourages the mentee from exploring their own possible options or solutions and driving their own agenda.
During the workshop we worked through a useful exercise to help appreciate this difference.
After listening to the mentee, the mentor was given the task of adopting two different approaches;
a) Give advice
b) Work through a structured set of questions instead;
As you can see, approach b) focusses on ‘success’ and positivity. These are open questions, allowing the mentee to create and explore their own agenda.
The ‘T-GROW’ approach to mentoring
The ‘T-GROW’ pneumonic provides a very useful structure to shape a mentoring session;
Before embarking on a mentorship session it is important to address ‘the contract.’ This defines the relationship between the mentor and the mentee, and provides the opportunity to explore each other’s expectations at the outset. It is important to emphasise the confidential nature of the meeting, unless of course any alarming information is shared.
How do I learn more?
Dr Tim Warlow
The Paediatric Palliative Care Team & Ty Hafan hospice are hosting another free conference at the Copthorne in Cardiff on the 9th May 2019.
It will involve interactive sessions on advanced care planning, decision making at the end of life and the All Wales ‘PAC’ Plan. This is one of the most challenging areas reported by new consultants in managing professional relationships and families.
We are hosting an expert panel including police, ambulance and organ donation teams, and a live interview with a bereaved parent with an open Q&A session. It promises to be a thoroughly engaging day with professionals from a variety of backgrounds represented, to tackle some of the most challenging aspects of paediatrics.
A hot lunch and refreshments are provided.
Currently within Paediatric training you have to opportunity after your core training to apply for sub speciality training within Paediatrics.
Info on the GRID process can be found here:
The list of sub-specialities available and information about them can be found here:
Having applied and been successful this year I thought it might be useful to have a blog post covering the best tips which I received along the way.
Dr Rebecca Broomfield
Before you start?
Firstly you need to decide if you even want to apply for a sub-speciality, and if you do then which one! I cannot start this blog by saying that I had always dreamed of being an Emergency Paediatrician - I had not. If I am completely honest for the first two years of my Paediatric training I mainly wanted to pass my exams. However, I was asked an important question the day after finding out that I had passed my clinical exam. (Literally the day after, thanks Dr Ian Morris!) He asked me what I wanted to be. My reply was a rather surprised, hopefully its clear I want to be a paediatrician, but it was the next question that really started me thinking - What do you want to do within that? It made me stop and made me question exactly what type of paediatrician I wanted to be. Now, I don't think he was necessarily asking what GRID I was going to apply for or meaning that I should sub-specialise but I started asking what I loved about my job, what I didn't enjoy and this made me realise that I needed a slightly more focused career aim than gaining my clinical exams and bobbing along through the rest of my training.
So, if you are at the start of your career, or even near the end - I ask you "What do you want to do within that?" Is a sub-speciality for you? Do you have an interest in medical education? Have you got a passion for clinical leadership? Have you always fancied a PhD? You might already know the answer. Or you might, like me, have not thought about it until somebody asked.
If you have decided on a sub-speciality then you need to start looking at your CV and tailoring it towards that focus. Personally I asked for a rotation in PEM. I attended PEM relevant conferences and took part in PEM research. The QI projects I undertook became more emergency focused and I attempted to gain insight into whether this was the place where I wanted to base my career by talking to the people already doing it.
The best tip I had here was to look at the marking scheme when you are writing your answers. You can have a fairly good idea of what you are going to score if you at least look at the criteria you are being judged against.
I started by brainstorming everything which I had been involved in. I didn't think I had much to go on to be completely honest when I started, but you'd be amazed how much you have actually achieved when you write it all down in one place! Once you have drafted answers and put words together on a page then ask people to read them! Ask as many people as you can from within your sub-speciality choice but also from outside it. Ask people who you consider to be friends but also people who you don't. Put yourself out there, brush away any imposter syndromes and get feedback on what you have actually written. Accept that they will all have different opinions with what you need to include to get top marks and realise that you will not be able to include it all. But the more people you ask to read it the better your answers will be.
Importantly don't be to modest - this application my be the only chance to sell yourself to the speciality which you want to be part of. The best feedback I got told me bluntly to sell myself more. It feels uncomfortable to most but it is necessary, nobody else is going to sell you. If you have done something amazing then shout about it!
This was possibly the most stressful experience of my career thus far. It is extremely uncomfortable for the majority of people to sit in front of a group of highly qualified experts in the field which you want to join and talk about yourself and how great you are for 20 minutes. If this doesn't come naturally to you then the only thing to do it to practise! Do mock interviews, record your answers to standard questions and play them back to yourself, talk to the mirror whatever you need to do to get comfortable doing it. My first mock interview was a disaster and the second one was even worse but I had a team around me who were willing to help me get better. I read a helpful consultant interview book, had thought of examples for key areas which could be adapted to answer a question, had structures for questions to avoid rambling and, most importantly, borrowed a friends lucky jacket (Thanks Kate!) While nothing can prepare you for the questions which they will ask, and there is always a question you would never have thought of, I felt as prepared as I could be when I hopped onto the long train from Cardiff to London on the day of my interview.
Practise and preparation are the key. (Plus a quick toilet based power pose in the RCPCH basement - Thanks Amy Cuddy)
Think about what happens if you get an offer
I did not do this.
Prior to submitting the application you have to rank the jobs which you would be willing to accept. I did this and truly believed that I had thought through all the pros and cons of each place - the 24 hours or so (ok, probably more like 72) of sobbing after my job offer came through suggests that the reality of the situation was slightly different to the expectation that I had had before. So I encourage you to think through the reality of what would happen if you were offered that job and what you would be willing to accept prior to clicking the submit button.
On that note, this is my last blog post as an editor for the WREN blog. Thank you for reading and taking this project from strength to strength.
I have been successful in my GRID application I will be starting my Paediatric Emergency training in September, however this will no longer be based in Wales. We felt it was important for the editors of the WREN blog to be based within the Wales Deanery. Annabel will be continuing and I am being replaced by Dr Tom Cromathy who has previously written guest blogs for us. I look forward to continuing to contribute and am sure the blog will be in safe hands!
Dr Siwan Lloyd ST4
I was very lucky to be able to attend the BPNA (British Paediatric Neurology Association)’s annual conference again this year. I attended with a poster presentation on “Single-centre case series of outcomes following switch from Levetiracetam to Brivaracetam”. I was also very pleased to see that two other Wales Deanery trainees also had posters at the conference: Emily Payne with her poster on “FLNA Mutation and Epilepsy – A Case Report” and Bethan McMinn with her poster on “Splints – to have and to hold”. The abstracts for these posters are published in the Developmental Medicine and Child Neurology Journal Volume 61, Issue S1.
The conference was held at the Titanic Hotel in Liverpool which was beautiful (unfortunately, my study budget did not stretch to me staying there and so I was in a Travelodge in the City Centre which wasn’t quite as glamorous).
The Conference Dinner was held in The Cunard Building with drinks beforehand in the British Music Experience where I got to see the Spice Girls’ original outfits and try out some electric guitars (and realise that my very few guitar chords that I learnt in University have long escaped my memory). There was also an evening Ceilidh which took me back to the many good times that I had at Ceilidhs during my 6 years in Edinburgh University.
I met many of the Paediatric Neurology GRID trainees who were extremely kind and helpful and allowed me to question them endlessly about what life is like as a Paediatric Neurology GRID trainee. They were extremely supportive in giving me career and applications advice. I would encourage anyone thinking of applying for any GRID specialty to go to the trainee meetings, contact the trainee representatives and attend the trainee sessions at the annual conferences for that specialty in order to meet as many current trainees as possible. The insight and advice that they can provide is invaluable when making difficult career decisions.
The conference had a very varied and packed programme and I will just briefly mention some of the most memorable talks.
There were speakers from across the world including Brazil, Ghana, Nova Scotia, Marseilles and Ecuador. It was extremely interesting to hear about their clinical experiences working in such different settings (e.g. experience of congenital Zika Syndrome in Brazil). It was also insightful to hear about experience of paediatric neurology services in Ghana and the challenges faced (e.g. limited access to newer AEDs/neuroimaging/lab support) and this again sparked my interest in Global Child Health and reminded me that we should really be striving for equality in paediatric services across the world. These talks also reminded me of the importance of hearing from clinicians working in other countries to gain insight in to conditions that they see more frequently than we do, and to understand the set-up of their services and share good practice.
As I’m sure you can imagine, there was a lot of discussion about cannabidiol use and the pressure that there has been from the media, support groups and politicians to prescribe these medications. There was evidence presented on RCTs assessing cannabidiol use in Lennox-Gastaut and Dravet syndrome and also drug interaction studies for co-administration of cannabidiol with other AEDs. These discussions highlighted to me the many emotive issues surrounding this topic which has been of huge media interest recently and the importance of rigorous research and evidence for any medications that we prescribe. The NICE guideline is expected in October 2019.
I attended two Personal Practice Sessions: the first on “Vestibular Disorders in Children” and the second on “Neuromuscular Disorders: Floppy Infant Diagnosis and Management” which were very useful.
There were many talks on the emerging advances in genetics: next generation sequencing, gene panels, exome sequencing, whole genome sequencing. In the personal practice session on Neuromuscular Disorders, the speaker informed us that genomic investigations are now becoming first line in many neurological presentations. He reflected on the difficulty with informed consent and that his healthboard now employs a genomic nurse practitioner to take informed consent and discuss these issues with families. Their service also runs a “Genomic MDT” to discuss all results and the significance of the variants before the result is fed back to the patient and families (they hold these MDTs once a month with tele-conferencing to DGHs). I thought this was an excellent idea and something that would be very useful to roll-out to other healthboards as these emerging technologies are becoming more commonplace in clinical practice.
There were presentations on the re-emergence of SSPE in the UK related to recent Measles outbreaks. It was heart-breaking to hear about these preventable cases. This inspired me to discuss vaccination with any parent/child that I assess during acute admissions and to try to do anything within my power to tackle the misinformation about vaccination which has led to so many tragic outbreaks of preventable diseases with devastating outcomes for some families.
One talk that I very much enjoyed was given by R Black and introduced a resource that she and her team had developed called “me and my epilepsy”. This was developed following a qualitative study which highlighted that children and young people with epilepsy had unmet information and support needs. It also highlighted that children’s understanding of epilepsy very much relied on their parents to provide information. An animation was developed alongside the children from the study and all words in the video are the children’s own words. This made me think about the information that we provide for our patients and highlighted the need for more child friendly information and resources to be available and to prevent the situation where parents are the only “gate-keepers of information”. This is important to ensure that all children have fair access to information about their condition. I would encourage you to watch this video and share with your patients with epilepsy: Muir Maxwell Epilepsy Centre – Me and My Epilepy URL: https://www.youtube.com/watch?v=MO7xXL2ZXP8
There was a lot of discussion about the new RCPCH Shape of training report and the impact this will have on future paediatric subspecialty training. Training is planned to be shortened to 7 years, with the introduction of credentialing and increasing opportunities for post-CCT training modules. It was interesting to see the way in which our training is likely to change significantly in its format over the next few years and I would encourage everyone to have a look at this report. It will impact us all whichever subspecialty we decide to pursue.
I would very much recommend the future BPNA conferences to any trainees who are interested in Neurology, Epilepsy, Neurodisability, Genetics or Community Paediatrics. The BPNA also have some excellent courses for interested trainees like the PET epilepsy training courses which I would also highly recommend to any trainee.
Dr Rachel Morris ST6 Neonatal GRID Trainee
My name is Rachel Morris and I am currently working as an ST6 neonatal registrar in Cardiff. Over the last 3 years I have also volunteered as a Dreamflight Doctor. Over this time, I have been fortunate to accompany 48 children - most of whom are from Wales - to Orlando for their holiday of a lifetime. WREN have kindly given me this opportunity to tell you about Dreamflight and what my role entails.
Dreamflight was co-founded in 1986 by two British Airways employees, Patricia Pearce and Derek Pereira. They had a dream of facilitating a trip for children with a serious illness or a disability to Disney World in Florida for a holiday they would never forget. After recruiting volunteer doctors, nurses and physiotherapists from around the UK, they embarked on their first trip in 1987. Now 31 years on Dreamflight has taken over 5000 deserving children from across the UK to Florida. Patricia and Derek have both subsequently been awarded an MBE for setting up such a remarkable, life changing charity.
Every October 192 children, aged between 8-14 years, make up 12 regional groups from across the UK, and board their very own private ‘Dreamflight' Jumbo Jet. Many of the children could not travel without the 24hr medical support Dreamflight provides. The children come on the trip without their parents, and may be their first taste of independence, often finding a confidence they didn't know they had.
I was asked if I would like to apply to Dreamflight when a vacancy came up in the welsh group. Having heard about the trip I did not hesitate to send in my CV and application. I then had an informal interview to secure my place. Being a Dreamflight doctor is like no other role I have taken on. You become part of the Dreamflight family and form life-long friendships. With each trip costing in the region of £800,000, all year round there are an army of dedicated Dreamflight volunteers that take on huge challenges and organise wacky events to ensure we meet the target.
Each time I travel with Dreamflight so many 'what if's' go through my mind. I worry about not knowing enough about each child's medical condition, terrified of what I would tell their parents if they were to become unwell. I think these thoughts will never go away and maybe shouldn't. But very soon into my first trip I realised my role on the trip was much more than being a doctor. In fact, with the support of the nurses and physio within my group, coupled with the incredible support and advice from Dreamflight’s Medical Director you share every major medical decision, which made that aspect of my role slightly easier.
Possibly more importantly I also act as an ‘escort’ - a parental figure to two of the children. I can only imagine how difficult it must be for families to hand over their children for 10 days, which is why all of the escorts begin to build relationships with the families from the time their child is selected and send updates when on the trip. It is comforting to be able to relay to the families about all the training and procedures the charity has in place to ensure all of our children are safe, well and happy.
Every volunteer would be expected to attend the annual briefing and training day, along with a welcome day for the families and children to meet prior to the trip.
While we are in Orlando, each regional group has lovingly chosen a character name - I am part of Team Shrek! (Being the Shrek Doc has a much nicer ring to it that being “The Pooh Doc”!)
Each team would have 3 radio holders so that the doctors and team leaders can communicate to share top tips, and request support should they need it. The entire team wear one colour and are easily identified in the busy theme parks, and we have hospital style drug charts to keep track of medications throughout the day.
My concerns as the group doctor keep me on my toes even if I’m upside down on a roller coaster! The desire to have that constant knowledge of how the children are feeling, are they getting too tired, have they taken their medications on time, do we have their lunch time medications with us, have they eaten the correct foods, are they well hydrated, are they constipated? As well trying not to be over bearing and give them that chance to be independent! Aghh! A very tricky balancing act and a majorly steep learning curve! It is reassuring to know you are not alone with these concerns, and the wonderful sense of team spirit with the experienced Dreamflighters in the team help to steer us all in the right direction and help create that balance.
Each doctor is on-call one night of the trip, the rest of the nights you are 'off duty' from 9pm when you handover to the night nurses and on-call doctor, attending handover again at 7am to resume your doctor/escort role.
As well as all the more serious responsibilities, we also ensure we make every day as fun as possible! This involves high quality costume preparation, singing, dancing and lots of partying. We have a different outfit every day, designed around a theme, for example we have 'festival theme', 'American theme', and my personal favourite 'tropical flamingo theme'! We have neon tutus, headscarves, incredible glitter face paints as well as wearing our Shrek ears at all times. I go nowhere without my retro 80s bum-bag, worn like a holster, sun-cream and calpol primed for action.
As a Dreamflight volunteer I work within an amazing group, headed up by our group leader Gillie Ticehurst, who is truly remarkable at making sure we all feel supported. During the trip we have a compulsory meeting/debrief every evening once the children have gone to bed. Going around the room, every single group member is asked to share any highs or lows from the day, any physical or emotional strain they may be experiencing. We support and discuss solutions to problems, ensuring work load is being fairly distributed. I have learnt a lot from the attention to wellbeing and peer support the charity offers to its volunteers. With the NHS putting more and more emphasis on wellbeing, it is meetings like this I hope we can incorporate more.
With regards to other aspects of my role, it is much more than the 10-day trip. From early February I start spreading the word of Dreamflight. Contacting junior doctors, consultants as well as all members of the MDT to nominate children. Without nominations, the trip simply cannot happen. This can be a major challenge, appreciating how little time health care workers have to dedicate to extra form filling. We then meet the children to carry out a medical assessment and give them a chance to get to know us. We may also need to do home visits to appreciate equipment needed. As a group of medics and non-medics we then work around the clock making sure everything is in place to ensure the trip runs as smoothly as possible.
As well as the crazy rollercoasters and outstanding themed entertainment they have opportunities to learn to swim, ride on the back of a dolphin and perform in our talent show in front of hundreds of people. An opportunity so many take up and thrive on. In 2008, eight of the returning Paralympians from Beijing, many of them medal-winning, had been Dreamflight children and say that Dreamflight was a real turning point in their lives.
Allow me to share with you a little extract from an email I received following our last trip, a parent of a child with insulin dependent diabetes wrote …'Before Orlando, L was very dependent on us. He was continuously nagged about his blood sugar, as a result he had really low confidence, he was miserable, angry and had very little freedom. Since being home he's like a totally different kid! He's so confident and capable! We've taken a massive step back allowing him to make his own choices. For the first time Saturday he went to a Halloween party for 3 hours alone and yesterday went to a mates house for the entire day ☺…'. I think this feedback really sums up why I feel so passionate about Dreamflight!
I cannot emphasize enough how the opportunities the children are given on Dreamflight impact on their future lives. I am passionate about what this small but mighty charity does for the children as I have seen first hand the genuine difference it can make to the children and their families. I assure you it’s far more than a holiday, it’s maybe that chance for a child to find acceptance for their condition, or the capacity to enjoy some independence while in a safe environment, a boost to their confidence perhaps, and for so many of them - a sense of belonging and friendship. For others - it could be just a break from the monotony of their treatment they deserve with the kind of medication that cannot be prescribed - that I guess is the magic of Dreamflight!
If you would like to know more about applying to be a Dreamflight doctor please contact me on firstname.lastname@example.org 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 programme in more detail...
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
I thought I knew what Paeds Palliative Care was. I thought it would be sad, but I would find the positives in knowing we were doing all we could in a sad situation. I thought it would be a really emotionally challenging job, and I thought I needed to try it to see if it was something that I could do as a career/special interest. So I volunteered.
Paediatric Palliative Care was a breath of fresh air to me. I had the time to think, reflect and give patients and their family my time. We didn’t have vast numbers of patients to get through on any given day. But those we did have, needed time.
As the registrar I was based in the hospital most days, but most of our patients were in the community. We had a big list of active patients, most of whom I never met in person. My working week was sparsely timetabled allowing plenty of time for community visits, MDTs, admin and even reflection, tutorials and learning. I would come in each morning, sit with a cup of tea (oh the joy!) and find out which of our patients were admitted in the hospital. I would catch up with the specialist nurse and either together or alone I would do a ward round. Usually this was touching base with the family, liaising with the team, and symptom reviews or Advanced Care Plan discussions. The families really appreciated someone from the Palliative Care Team being there – even though I didn’t necessarily know the family initially, I was a member of a team who really knew their patients well and therefore a link to this support network.
I would do a weekly round in Ty Hafan, the Children’s Hospice, with the consultant. Most of the children were there for respite, so were very well and enjoying life. Seeing the children in Ty Hafan really highlighted to me that we can get a completely different view of a child by only seeing them acutely unwell in the hospital. One stark example was a child I saw when doing an acute General Paeds shift overnight who was thought to be end of life on the ward. He was transferred out to the Children’s Hospice where I saw him again a week later – snuggling in bed with his pet dog - although minimally mobile and outwardly inexpressive, clearly getting joy from his companion. Children and their families are often so much more relaxed in the hospice environment - clearly happy and comfortable. It's hard to remember this when you only see them on the inpatient ward or unwell in the assessment unit. My experience in Palliative Care has definitely opened my eyes wide.
I learnt about the common symptoms, how to assess the cause, and how to tailor the management holistically for that individual. I revised some pharmacology and gained confidence in prescribing symptom control medications, but realised drugs weren’t the only solution, and thinking outside the box was needed. Pain is so much more than just physical.
Difficult conversations became more normal. I realised that often it is more difficult in anticipation, but when talking to the family it felt almost natural to discuss death and dying – they had been thinking it anyway. We had the luxury of longstanding relationships with these families, and the most wonderful nurse specialists who knew how much to say, when, and just how to say it. I learnt so much from being with them.
Paediatric Palliative Care is not solely end of life care. It is being there, supporting children, families and their medical/nursing teams through the ups and downs of their condition. It is holistic care.
If you ever get the opportunity to have a taster in Paediatric Palliative Care, whether it is a day or one of your rotations, the fantastic team of doctors, specialist nurses and the huge number of support staff will welcome you and I can guarantee you will learn more than you ever imagined you would.
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.
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:
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.
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:
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:
“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.
Assim Ali Javaid – ST3
Paediatric trainees in Wales are a lucky bunch in many ways but one of my personal favourites is the chance to spend your ST3 year as an academic year. As far as I know, Wales Deanery is the only one that offers this option. Everywhere else you’re either on an official Academic Training Fellow Programme or not. Wales Deanery has been running the Academic ST3 Year option for the last 3 years and it offers paediatric trainees in Wales a chance to explore interests in research and/or teaching before formally entering Level 2 training. This is done alongside providing out of hours clinical cover at the University Hospital of Wales (UHW), usually as the Specialty SHO on call. There is only one Academic ST3 post available per year and it is largely up to the trainee who gets the post how they use the year. As such, every trainee who has had the post for the last 3 years has had a different experience.
In my case, I have an interest in research and teaching and wanted to explore something related to Paediatric Emergency Medicine. After discussing options with various consultants, I decided to join Professor Alison Kemp’s team and explore burns injuries in children from a safeguarding perspective. Alongside this I have offered to cover a clinical trial being carried out by the UHW Research Unit, taken up multiple teaching opportunities and started a Postgraduate Certificate in Medical Education. With all this on my plate, my day-to-day work varies greatly and I don’t have a typical “day” of work. In order to give you an idea of what I’ve done with this year I’ll briefly mention the different roles I’ve taken on. It’s worth remembering though, that this is a very flexible year and there are a number of other ways to use the time.
The bulk of my work is based in research. The burns team I work with has a database of around 4,000 burns cases with huge amounts of usable data recorded for each case. After deciding on a couple of research questions with Professor Kemp, most of my time is spent reading through the relevant literature, working with the database and trying to answer it. Proposing and answering research questions uses an entirely different set of skills to managing patients on the ward and one of the main advantages to this year is getting a chance to exercise a set of cognitive functions we rarely get to use in clinical practice. For those unfamiliar with statistical analysis, as I was, this can be pretty daunting at first but as you have no in-hours clinical commitments, there is plenty of time to learn how to work with biostatistics.
This would essentially be all I did during the day if I hadn’t chosen to take up a number of extra activities to break the monotony of research. During most weeks I will have two to four half day sessions dedicated to doing some of this extra work. I provide clinical cover for a trial being carried out at the Research Unit in UHW, for which my job is writing prescriptions, doing blood tests, interpreting ECGs and assessing any children who become acutely unwell while participating in the trial. Alongside this I spend a lot of time teaching. There are numerous teaching opportunities with UHW or Cardiff University and, I should point out, all are available for anyone to help with. However, the advantages of being an Academic Trainee is that, first, you have the time available to do a lot of teaching and, secondly, you’re often one of the first trainees to come to mind when Consultants or registrars are looking for help with teaching. So far this year I’ve been involved with teaching clinical skills to medical students, facilitating ethical debates between medical students, providing teaching to medical students on paediatric emergencies and paediatric prescribing, helping with mock paediatric exams for medical students at UHW, being a clinical tutor to final year students doing a module in Patient Safety, doing paediatric simulation training with final year medical students and providing teaching sessions for paediatric trainees due to sit their MRCPCH written or clinical exams.
There are considerable out of hour’s responsibilities too. The Academic ST3 usually goes on to the Specialty SHO on call rota, which is 50% banded at present, providing out of hours cover for Surgery, Neurology, Cardiology, Respiratory, Renal and Oncology. However, another great advantage to being an ST3 at UHW is the option to step up and cover your on call shifts as the Registrar instead. UHW is a nice place to do this as you’ll be paired with registrar covering General Paediatrics (usually more senior than yourself) and there’s an onsite PICU registrar for help also. Of course stepping up to Registrar is entirely optional and the post is based on the assumption of SHO level cover.
If you’re considering applying for the Academic post for ST3 there is only one place available per year, so it can be competitive. In order to qualify, the applicant has to be on course to have completed their membership exams, i.e. all the written papers and the clinical exam, by the end of ST2. If that’s the case, what you need to consider is whether this is what you’d like to do with your ST3 year. Trainees who aren’t particularly interested in research or teaching, those who want to get as much SHO level clinical experience before entering Level 2 training or those who want to skip ST3 altogether and go straight to ST4 probably have little to gain from spending their ST3 year on an Academic post. It’s also not particularly great for those who want to gain early experience in a particular sub-specialty in UHW, with a possible future SPIN or Grid application in mind.
However, this is a fantastic post for anyone with an interest in research and/or teaching, for those looking to improve their CV for a future Grid application or those who just want a bit of a break from constant clinical practice. It’s a rare chance to experience something outside of clinical practice, without having to take time out of the programme in order to accomplish it. Personally, I can’t recommend the Academic post highly enough!
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.
“Big surf” in the Australian Life Saving Ironman @ Queenscliff Life Saving Club
Nat and I with the Rottnest star of the show aka “The Quokka”
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!
The Work: Positives
Dr Smarty Pants, hard at work… at Westmead Children’s Hospital
The Work: Negatives
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.email@example.com.
Patient’s parent: She’s been crook for days mate?
Doctor: Nah no worries mate, she’ll be right!
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.
Thank you to Lisa Budd for her photograph from California
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?
Thank you to Lisa Budd for her photograph from California
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).
Whereas I prefer to build the ideas of mindfulness into what I am already doing. I use my walk home as an opportunity to focus on the scene around me, the colour of the trees and the movement of my feet. If that’s more up your street, try choosing one thing to do with more intent and curiosity. When brushing your teeth, notice the sensation of the bristles and taste of the toothpaste; when washing up, pay attention to the temperature of the water and the squeaky sound of the sponge; or perhaps sit down to really enjoy that cup of tea, rather than picking up your mug to take a sip only to find you’ve drunk it all!
So instead of multitasking, maybe it is time to try focusing your attention on just one thing? Purposefully and non-judgmentally. You won’t do it perfectly and you will get distracted. But that’s ok. Mindfulness isn’t about getting it right, it’s all about noticing, accepting and refocusing, many times over.
“The little things? The little moments? They aren’t little.” – Jon Kabat-Zinn
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
Earlier this month I attended the Wales Neonatal Network Audit & QI Day and a hot topic for discussion was sepsis and the use of antibiotics. The sepsis risk calculator (SRC) is a fairly new concept due for implementation in neonatal units across Wales early next year…but what does it involve?!
What is the sepsis risk calculator?
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.
Why is it important?
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.
The calculator in more detail…
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
Implementation of the Sepsis Risk Calculator…
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
So…what do you think?
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!
30th October 2018, RCPCH London
Dr Chris Course
The RCPCH and the NIHR (National Institute for Health Research) held annual joint study day aimed at promoting and de-mystifying academic training careers. This free study day is fairly new on the RCPCH events calendar, having only been held for the past couple of years, but aims to tackle an area of training which is sometimes perceived as difficult to understand and undertake.
This was my first trip to RCPCH HQ in London, and it was great to actually see the place where its all run from. Despite not being as grand as the Royal College of Surgeons or GPs, it was a modern building with good meeting facilities. I was also a little worried that, not already been on an academic training pathway, I may be a little “out-of-it” or some of the subject matter may not be useful or attainable for me.
Thankfully, I was wrong! There was a really good mix of trainees in attendance with a wide range of backgrounds. Some were already undertaking PhDs, some were nearing the end of their training and looking to build a research career, some were already on an academic training fellowship. Meeting all these colleagues with different backgrounds in the “Networking” session during the morning helped me to put my own current aspirations and difficulties into context and to being finding some solutions to these problems.
The speakers for the day were an eminent bunch and gave some really useful and insightful talks. Professor Anne Greenough started the day with a broad introduction to academic career paths, and how the new progress curriculum is building research and academia into the training domains, aiming to improve our exposure to clinical research, as well as encouraging the Deaneries to facilitate more academic opportunities. Dr Chris Gale then gave his personal experience of his path into an academic career, giving a “how-to” guide too framing a research question, finding the supervisors and mentors to help develop your project and then how to find the grant money. It was encouraging to hear how perseverance is the key to obtaining the funding, and giving hope that somebody wold fund your project if you’ve had a good idea! The morning was rounded off by Professor Paul Dimitri trying to de-mystify the NIHR – not an easy task! It seems to be a very complex structure, and I can’t say I understand how they work completely, but I’ve definitely got a better idea of where to find more information now. There was also good formation on how to further an academic career as a trainee and consultant after completing your initial projects.
The afternoon included workshops from Dr Lauren Kier from the Wellcome trust, covering tips on grant application writing and how to secure that all-important funding, and balancing clinical and academic priorities through your training grades. Following this, there was a presentation covering developing a career in industry, and leaving clinical medicine. I can’t say this talk filled me with inspiration, but it was a interesting to hear the experiences of life outside of clinical medicine with a medical degree. The day was a rounded off with an entertaining talk from Professor Mike Levin, giving an overview of “A journey into research with no plan”, and how an inquisitive mind and a bit of serendipity can help forge an academic career. I’m not sure if the much more structured and formalised training career we have now, with portfolio and ARCP demands, would still allow such a career path, but it was interesting all the same.
I would recommend the Academic Trainees Day to anyone contemplating an academic training path or thinking about taking time out of training to do research. Also highlighted in the day was the RCPCH’s Academic Toolkit www.academictoolkit.org which is another useful resource for anyone wanting to know more about academic careers. The day highlighted the challenges and obstacles to an academic career, and how to start overcoming them, and was a good networking opportunity to learn of other peoples experiences. The day showed that an academic career can be a challenging one to start and maintain, but can be incredibly rewarding.
Dr Rebecca Broomfield
A summary of a year taken out of program to pursue an interest in clinical leadership.
During the last year I have spent my time as a Welsh Clinical Leadership Fellow. While we want to use this blog to promote research and education we also want to highlight opportunities that we have within Wales for trainees. The year as a Leadership Fellow was one of the hardest but most enjoyable of my career. I have blogged on here individually about some of the fantastic opportunities which I was able to attend. I encourage you to look up the posts on the Faculty of Medical Leadership and Management Leaders in Healthcare conference and the blog on the Neuroscience of Leadership course at MIT to name a few. In this summary post I want to give you an overview of why I think clinical leadership is so important and what this year involved
Why do it? Is it even important?
Leadership is everyone’s business. As you go through your career you will be but into leadership positions even if you don’t think that you are. Everybody within medicine is a leader in some way and therefore surely it is important to learn the skills to be a good one? We teach other things, procedures, history taking, interpretation of investigations so why not teach leadership? I believe there is some weight in the argument that leaders are born, not made in that some people will naturally gravitate to and thrive in leadership positions. But every leader can improve, and therefore good leadership can be taught. If as trainees we are given an opportunity to learn these skills then this can only be a good thing for the future of health care.
The Faculty of Medical Leadership and Management Trainee steering group is a fantastic resource for trainees. (https://www.fmlm.ac.uk/about-us/networks-and-groups/trainee-steering-group). They have just published a toolkit which outlines the importance of clinical leadership more eloquently than I can summate in this paragraph. It offers hints and tips to expand your own leadership styles without having to take a year out like I did. This can be found here: https://www.fmlm.ac.uk/members/resources/leading-as-a-junior-doctor
When I started this year, I anticipated that the patient improvement project which I had selected to do would be the complete focus of my attention but actually this was a very small part of the lasting impression I have from this year. My project was based within the medical education department at Cardiff and Vale Health Board. I worked with the simulation team changing the way which we collected feedback from our simulation courses, helping with the development of a new simulation suite, designing and leading new simulation courses and co-ordinating a innovative in-situ simulation program to tackle falls.
My supervisor Dr John Dunne was fantastic, alongside Miss Melanie Cotter they gave me freedom which I have not had in a structured training program to pursue my own interests and develop my project as we went along. Because of this I probably worked harder than I ever have, but also enjoyed work more than I ever did. My project actually became more of a tool in which to try out different leadership styles and the hints and tips we were learning as part of the PGCert in Leadership and management. It was successful and will leave a sustainable change within the medical education department.
As fellows we were all encouraged to take steps to select a project that was outside our comfort zone. While I did have a previous interest in medical education and simulation I am a paediatrican and a lot of my work this year has been done within adult specialities. The projects which we had very varied and extremely different but all offered the same opportunities and similar enough experiences.
This is the qualification which runs throughout the Leadership Fellow year. It is run by Academi Wales through Trinity St David University. The course gives you a qualification at the end of the year and is a big difference in Wales when compared to the clinical leadership opportunities offered in England, Scotland and Northern Ireland. There were structured sessions spaced throughout the year which were attended by a wide variety of participants outside the fellowship program (clinical directors, speech and language directors and dentistry leaders to mention a few.) These focused on a variety of different areas within clinical leadership. Teaching different leadership styles, exploring coaching qualifications and self reflection with tools such as Myers-Briggs. The best session was the team building session in Elan Valley – again on this site there is a blog post dedicated to this experience.
As a tip to this years Welsh Clinical Leadership Fellows – write your project up before you go back to clinical rotations! Right now, when I’m writing the essays, I wish I’d followed this advise from the year before me 😊
I have been able to develop myself more in this year than in the whole of training so far. I have had the opportunity to analyse my behaviour looking at my preferences, understand when they might not be the best option and how to make them work for me. I have been taught the tools to look at difficult situations from different perspectives and recognise that not everybody thinks like me! – This in itself seems simple, obviously not everybody thinks the same but I was really able to explore just how different other peoples viewpoints were. By being able to see and appreciate these, not necessarily agree, you can avoid a great deal of conflict and confusion. Resulting in, as well as from, poor leadership. But I was also taught how to deal with conflict, how to turn challenge and opposition into a unifying aspect rather than a dividing one. I have learnt to ask for forgiveness, not permission and have been given the confidence to express my opinion. I have explored my own personality and learnt to look after myself. I hope to work in the emergency department and these skills will be invaluable as I go through my career to increase my emotional intelligence and resilience.
It was HARD work.
The first few months finding your feet and trying to work out what direction you wanted your project to go in were really difficult. As trainees we come from very structured environments, rotating from job to job, thinking in 6 month blocks and ticking off targets to pass the ARCP. This year was different, at the start there were no targets, you had to make and develop them yourself. You had to become used to managing your own diary. Not having to clock in and clock out was very liberating but also intense. As a group we handled this either by working every hour never really clocking off, in order to justify our time or by spending a while drifting around not really achieving much with he vast amount of time offered to us. This evened out in the end as we learnt the skills which came with the freedom. It was your responsibility to create opportunities rather than somebody handing them to you. And networking is a skill which can only be achieved through practise and comes easier to some than others.
On a personal note, I was also away for large chucks of time from my family home. I have 2 small children aged 5 and 3 and part of this year was to have the flexibility to see them more frequently. I’m not sure I achieved that, being on a plane to Boston while my daughter was on stage at St David’s Hall in her first ballet show was a particular low point. (Thanks go to my Mum for stepping into that!)
The pros far outweigh the cons. I have learnt so much more about who I am. What is good about my leadership style but also what I need to work on. My biggest learning point from this year is to respond not react, something that I didn’t even recognise I was doing until this year. I have had the opportunity to develop a long lasting quality improvement project, which is sustainable even after I have left my post. But I worked hard, I created my own opportunities and spent less time with my family than I would have liked.
Would I do it all again? … Absolutely!
If you are interested in applying for the Welsh Clinical Leadership Year and want me information please do contact me, I’d be more than happy to chat over coffee.
Guest Blog from Dr Katie Greenwood ST8
Hello! Thank you WREN team for giving me the opportunity to share my experiences over the past few years with you.
Life as a paediatric trainee can be one of considerable stimulation, compassion, challenge and significant reward. The desire to deliver a very high standard of performance and achieve excellence within the workplace, has made me recognise the importance of developing exciting out of hours interests and achievements. Alongside working hard as a senior paediatric trainee, I have developed a passion for competing in triathlons and have participated in a number of challenging races across the world.
Where did it all begin?......…
A friend mentioned joining the Cardiff Triathlon club, apparently the fastest growing club within the UK. I pondered the idea of joining the team. Here are a few initial thoughts which crossed my mind:
- How on earth do people manage to swim/cycle/run within one race?
- Open water swimming in the UK sounded particularly un-exotic!
- How does a busy paediatric trainee fit in the training for this challenging sport?
After joining the club I started my racing career with a low key Cardiff “try-a-tri” triathlon and finished the same season with a race in the French alps….the famous (and brutal!) Alpe D’huez mountain climb. Oh dear!
From these moments on, I haven’t looked back! Over the past few years I have been fortunate enough to win both the Sprint and Standard distance Welsh Champion triathlon titles.
I have also been selected to compete for Great Britain (‘GB Age group Team’) at the 2017 World Triathlon Championships in Rotterdam and European Championships 2018 & 2017 in Estonia and Dusseldorf Germany. I was absolutely delighted to represent team GB and finish in the top 10 in each race.
So what does all this involve?
I would encourage everyone to enjoy a hobby outside of work and if you are interested come and join the triathlon club. Immense enjoyment can be experienced at every level and it is a fantastic way to meet new people and keep fit ready for the workplace!
Dr Chris Course
The European Respiratory Society held their annual Congress for 2018 in Porte de Versailles conference centre, Paris. The European Respiratory Society is a non-profit organisation which aims to promote lung health and drive standards for respiratory medicine globally. In addition to publishing the European Respiratory Journal and educational handbooks, the annual congress is the largest respiratory conference in the world, covering topics on respiratory health and disease from fetal life to old age.
Having registered months ago, (with an excellent discount on the registration fee for the honour of being under 40!) the congress program arrived in my inbox a few weeks ago, and to say it was overwhelming was an understatement. There were numerous concurrent sessions, across three floors of the conference venue, with special seminars and workshops on topics from non-invasive ventilation in adults, to bronchoscopy, lung ultrasound and inhalers for COPD. Having a paediatric/neonatal interest made it much simpler, as once you had filtered out all of the adult program, there was a manageable range of choices!
The whole conference ran across four to five days, with the majority of the paediatric program running across the middle three days. The quality of presentations was high, and the speakers were clearly eminent in their field. Despite being a “European” conference there were speakers from across the world. I had gone with Professor Sailesh Kotecha and members of the research team at the School of Child Health, Cardiff University, and Professor Iolo Doull from the Paediatric Respiratory Medicine team in Cardiff.
The first day we attended sessions on Prematurity and Lung Disease which included work presented by David Gallacher (Neonatal GRID trainee, Wales) from work he conducted with the School of Child Health at Cardiff University looking at pro-inflammatory cascades in the Preterm lung. Presentations also included work on Ureaplasma treatment for Preterms, animal models looking at effects of different durations of mechanical ventilation on long term alveolar structure and the Forced Oscillatory Technique for real-time assessment of preterm baby’s lung mechanics. The afternoon had an excellent Paediatrics Year in Review session looking at the top literature from the last year, the highlight of which was Dr Ian Balfour-Lynn (Royal Brompton, London) presenting the last year’s work on Cystic Fibrosis disease modifying drugs like Ivacaftor and Orkambi.
The second day started with the Paediatric Grand Round where challenging cases and unusual diagnoses were presented and discussed, and this brought a good contrast to some of the talks from the first day on mechanistic and translational science. This as followed later in the day with a Lungs on Fire session where quick fire case presentations and questions were put to a panel of experts and the audience with the opportunity for us to vote along – this gave me confidence that some timers no-one knows what the right answer should be! Another session looked at the infectious causes of wheeze and asthma and our current knowledge in their manipulation. Talks included work on the microbiome of the upper airways, and our current evidence base for the treatment of pre-school wheeze, and it looks like Montelukast is out again! A running theme across the first two days was the quantity of work looking at azithromycin for the treatment of a range of conditions, and although lots of the evidence was convincing, I was occasionally left wondering if it’s the current fashionable treatment or a drug with further unexplored potential.
The second day ended with the paediatric dinner, which started with a boat trip down the Seine, followed by dinner at the foot of the Eiffel Tower. This was a great evening and opportunity to escape the conference venue. As much as I enjoy a good conference, the inside of a presentation hall is pretty much the same wherever you are, and it was nice to get out and see a little of the City of Lights. Dinner was interesting (the starter consisted of a mixture of tuna steak and strawberries…) but so was the opportunity to meet new people from across Europe and the world.
The last day (slightly tired!) we got in nice and early, mainly because our posters had to go up! After a coffee and a croissant, we headed to the first session on Prenatal Origins of Respiratory and Atopic Disorders which included data from the COPSAC (Copenhagen birth cohort) studies and animal models looking at how maternal smoking, and interestingly “vaping” may affect offspring into adult life. It also highlighted the scientific, economic and clinical difficulties in managing such large birth cohort studies and how replicating results can be challenging. Following this, we attended a session on Advances in Primary Ciliary Dyskinesia. This covered pathophysiology of this rare and little understood disease and highlighted how genetic are changing diagnosis. However, it was rightly pointed out after the presentations that, much as with Cystic Fibrosis, the phenotypic variance of these genotypes is still not clearly understood, and the continuing importance of expert interpretation of histological samples and formation of centres of excellence to manage this condition.
We ended the ERS by having a walk through the exhibitors hall. There was a great ‘Game Zone’ where we could play with video laryngoscopes, bronchoscope and thoracic ultrasounds and it was great to have a go with bits of kits that we’d seen or heard about but had little experience with. Tutors were on hand thankfully to guide us through the finer details! We also had a look through the commercial and pharmaceutical exhibition areas, which looked more like a new car show at times (not sure a hologram is really required to advertise an inhaler) and there was a paucity of the free pens, but there were plenty of places to sit and have a quiet five minutes, which was much needed by this point!
Overall, the ERS Congress was a fantastic experience. Definitely the best organised, highest quality, best value meeting I’ve ever been to, and would thoroughly recommend to anyone with a respiratory interest.
Next year the congress is heading to Madrid, check out www.ersnet.org for more information
Faculty of Medical Leadership and Management Wales Regional Conference 2018
13th September 2018
Dr Rebecca Broomfield
While I have completed my year as a Welsh Clinical Leadership Fellow (Blog post teaser … more on that in Novembers posts!) I still very much have an interest in leadership and how we can rise to the current challenges facing the National Health Service. Therefore I was excited to learn that the FMLM were hosting a conference just up the road in Cardiff.
It was a heavily packed program and the day flew by in a flash. The FMLM Chief Executive Mr Peter Lees spoke to us about the aims and targets of FMLM and how they plan to achieve this.
He was followed by Wales' very own Chief Medical Officer Dr Frank Atherton who opened with "If we don't seize the opportunity as medical leaders …. who will?" He emphasised the need for whole system change not jus on an individual level and that as an NHS in Wales we do not simply need more. We need to harness ideas and bring them together. We need to keep patient safety at the centre of everything we do and bring those who resist change with us through the changes which need to occur.
Following the CMO is always a tough gig but it was managed superbly by Dr David Samuel (A fellow Leadership Fellow Alumni) and Dr Sian Lewis. They reminded us of the need for diversity in the workplace and within medical leadership teams. They asked us to do a tabletop exercise to emphasise this point. Each member of the team picked a O or a X card. We were not able to tell each other which symbol we were. Then everybody shut their eyes and the X's were instructed to open their eyes and read the instructions. The task was to plan a holiday but to do so without giving any value or time to the O members of your table. Then the O's reopened their eyes and the task of organising a holiday was given to the table. I was an X. It was incredibly difficult to ignore and not give value to peoples suggestions. It felt awkward and non productive to an effective team working environment. The O's felt undervalued, and eventually gave up suggesting things and went off into their own discussion, effectively planning a whole other holiday. The exercise was trivial but raised a good point - are you really inclusive in your leadership? Do you consciously or unconsciously bias against somebody and importantly how does that effect the team.
Post a quick coffee stop we heard from Mr Nigel Edwards (Chief executive, Nuffield Trust) about integrated care and Dame Clare Marx (Current Chair of FMLM, former President of the Royal College of Surgeons, soon to be Chair of the GMC and a dynamic powerful woman) She spoke about the importance of clinical leadership and the fact that we need to change. She suggested that we need to exchange hierarchy for connectivity and that clinical leadership can impact to increase quality, social performance and make financial gains. She believes that positivity has a big impact on your team and that we have a responsibility to coach clinical leaders and help people to develop themselves.
Following this we had the unique opportunity to have a panel discussion on current leadership challenges and how we can embrace them and continue to move forward within Wales. We asked for their key Leadership message:
Dr Frank Atherton - To use management experience from outside of Medicine and promote interdisciplinary working.
Dame Clare Marx - The only thing you can control in life is yourself, the way you work and the way you behave. Understand what it is you have the ability to control.
Mr Nigel Edwards - Connect what feels real, we are missing a narrative "tell a story"
After lunch we were encouraged by Ms Katie Laugharne (Head of Welsh affairs at the GMC) and Dr Madhu Kannan (Current Welsh Clinical Leadership Fellow within the GMC) to think about Leadership expectations and impact. How the things you do day to day have an impact and how small things, like tea!, can really matter. We were encourage to think about how our leadership style was viewed by members of our teams and if that was the way we wanted it to be.
After a quick coffee break we learnt from Mr Christian Servini about what the future generations act was enabling people to do in Wales and the impact this was having on Well-being. Then to end the day a quick fire 5 minute presentation round where we heard about improvement projects which were having an impact around Wales. My project (poster below) was one of those presented.
If you are at all interested in Clinical Leadership I would encourage you to take a look at the FMLM website and consider going to the annual conference. Leaders in Healthcare details of this can be found here: https://www.fmlm.ac.uk/events/leaders-in-healthcare-2018
Dr Annabel Greenwood ST3
This is the first (hopefully of many!) of a new blog feature entitled ‘a day in the life of….’
Rebecca and I thought the blog would provide an excellent platform to share experiences of various opportunities and achievements, including paediatric speciality medicine posts, and out-of-programme experiences, both academic and non-medicine related, inspiring readers to explore something new to enhance and enrich their paediatric training.
It gives me great pleasure to debut this new blog feature by sharing my experiences of paediatric oncology. Having just completed my 6-month ST3 post, there is absolutely no question that I would recommend it to my fellow trainees! I hope by the end of reading this blog some of the misnomers associated with the world of paediatric oncology will have been dispelled.
Now, I’ll be completely honest with you…when I was first given ‘paediatric oncology’ as my ST3 rotation, I was a little apprehensive to say the least. My previous exposure to oncology had been only brief encounters during out-of-hours speciality cover, treading water until handover. The complexity of the patients, the mind-field of chemotherapy regimens, and the ‘sick’ potential of the febrile neutropaenia patients is enough to induce a resting tachycardia just thinking about it right?! Let alone managing such situations!
Fast forward 6 months, and my feelings as I walk onto the ward each morning couldn’t be further from that overwhelming uncertainty at the outset. And these are just some of the reasons why;
1. Teamwork: The MDT on the paediatric ward is truly wonderful and you feel part of the ‘family’ in no time. The nurses and nurse specialists know everything about their patients and chemotherapy regimens, and are always happy to help, the play specialists have an incredible way of boosting morale and making what can sometimes feel impossible, possible, and the consultants are very ‘hands-on,’ supportive and approachable. I sometimes don’t know where I’d be without the knowledge and advice of the pharmacists, not to mention to the wonderful physios, dieticians, and psychologists.
2. Variety: There is no denying that paediatric oncology is one of the busiest jobs in the hospital. The days can be relentless and sometimes it feels like you spend hours sorting the smallest of tasks, yet it’s often the smallest things that can make the biggest difference to both patients and their families. No two days are the same, from daybed reviews to the ward management of both haematology and oncology inpatients…every day brings new challenges and experiences.
3. Organisational/management skills: New patients often need investigations and procedures sorting quickly, involving liaison with the anaesthetists, surgeons and radiologists. There is a weekly ‘lines list’ to be coordinated for insertion/removal of portacaths/hickmann lines, and there is a weekly ‘planning meeting’ to discuss and arrange patients to be admitted for chemotherapy, investigations or procedures.
4. Practical procedures: There is a small theatre room on the ward for the weekly list of bone marrow aspirates, lumbar punctures and intrathecal chemotherapy. This is primarily led by the consultants and registrars.
5. The management of sick kids: Oncology and haematology patients have the potential to get really sick, quickly. Neutropaenic patients on chemotherapy can become profoundly septic, and sickle cell patients can present in an acute crisis. Coordinating the management of such patients although stressful, is excellent preparation for transitioning to middle grade training. There are protocols for the management of various situations, and as mentioned previously, there is always support provided by the consultant.
6. Emotional aspect: One of my principal anxieties before starting the rotation was how to handle the emotional aspect of the job. Of course, there can be devastating situations where treatment is unsuccessful, however, the kids are incredible, so resilient and courageous, and certainly serve to put things into perspective. Many of the children return to the ward on a regular basis for reviews and chemotherapy, so you really get to know the children and their families, and play a significant part along their treatment ‘journey.’
Of course like most jobs there can be days where there is no spring in my step along the ward, however, the positives far outweigh the negatives, and I am so grateful for the opportunity to experience such a truly wonderful job.
If you've done a unique job and want to share your experiences as a blog post then email either Rebecca or Annabel to share different experiences.
‘The Palliative Care Journey: Managing Uncertainty’
Guest blogger Dr Tim Warlow
All Wales Paediatric Palliative Care Network
Following the success of last years All Wales Paediatric Palliative Care Network Conference, the team are excited to introduce the much anticipated 2018 conference. This year we will be exploring the palliative care journey from the perspective of the child and family. Hearing from the families themselves, the day will follow their journey from diagnosis through to bereavement. Some of the questions we will be asking include:
• When should palliative care be introduced and how do I raise the issue with families?
• How do I support families whilst making difficult decisions about their child’s care?
• What are the spiritual needs of families at the end of their child’s life?
• How do I manage difficult and unfamiliar symptoms at the end of life?
• How do I approach uncertainty and grief?
• How can Ty Hafan Children’s Hospice help me to provide holistic care to families?
When working with families of sick children, many of the most challenging issues we face are also the most rewarding when done well. This day aims to unveil those daunting aspects of care, provide ample opportunity for discussion, and hearing from the expert parents and professionals as to how we can serve our families better.
The morning will focus on introducing palliative care and decision making, especially relevant in light of recent high-profile media cases. We will consider how we can involve children better in decisions relating to their care, collaborating with families to ensure they feel listened to and valued whilst navigating legal and ethical uncertainties.
Next we will hear from families of children with life limiting conditions themselves. What were the most challenging times, and what actions of professionals were key to their palliative care journey? What was helpful, what was harmful? We will consider how each professional on their journey played a key role in ensuring excellent holistic palliative care and what we can learn from one another.
Finally, the afternoon will include a series of breakout groups to provide opportunity to really get stuck in exploring an aspect of the palliative care journey that is a priority for you. There will be time to discuss and ask questions in a smaller group setting. Topics include supporting children and families at the end of life, managing difficult symptoms, supporting grief, bereavement and spiritual care, and how to support staff including debriefing.
Last year’s conference was booked up quickly and over 100 delegates had a fantastic day. Now in its fourth year we have built on the lessons of previous years, responded to your feedback, and produced a day which promises to be challenging, rewarding, and a fascinating insight into the lives of our patients and families through their own eyes.
Here is some feedback from last year’s conference as a taster of what delegates took away:
“Learnt many new things. Was challenged on preconceptions and pre-existing myths of Palliative Care. Enjoyed the professional, but personal element for some speakers / discussions.”
“ Excellent day from start to finish, sessions we interesting, informative and thought provoking.”
“I was hooked from start to finish”
“The case studies/discussion groups with the panel of different professionals involved with the neonate and their families’ journey were excellent and thought provoking. These were great for learning about how processes can work well and can adapt along the way.”
We look forward to you joining us in October
Date: 18th October 2018
• Location: Park Inn by Radisson Hotel, Cardiff City Centre
• Cost: £32 per person (£16 subsidised tickets available for students and upon individual request)
• Bookings and information: firstname.lastname@example.org
9th-10th July 2018
Dr Rebecca Broomfield
The Patient Safety Congress aims to transform the UK’s approach to delivering high quality care. It champions patient safety as the organising principle of a healthcare system which is truly efficient, effective and able to offer the best experience to patients and carers.
I was lucky to be able to attend the Conference in Manchester in July. Prior to attending I had minimal experience with the Health Service Journal who sponsor the event and although clearly focusing my training and clinical work on optimising patient safety I knew very little about this movement within healthcare. The HSJ run awards and publish a journal purely focusing on and publishing patient safety initiatives and ways which can all make out practice patient focused and as safe as possible.
The conference was busy and if I am completely honest the timetable when I first looked at it was completely overwhelming. There was key note lectures which drew the participants together and then 5 streams running throughout the 2 days which you could dip in and out of to cover the sessions which most interested you and met your personal learning needs. Along with an exhibition centre and poster presentations focusing on 9 different topic areas.
Unfortunately due to childcare compromises (working parent problems!) I wasn’t able to travel up to Manchester until the Monday morning so missed the opening keynote speakers which I was reliably informed were excellent and predicted the exit of The Right Honourable Jeremy Hunt from his health secretary post, but unfortunately the predicted replacement Dr Kevin Fong turned out to be less accurate!
When I arrived I set up shop in the Human Factors stream. The streams for day 1 were: Human factors, Delivering quality improvement on the frontline, Driving a culture of patient safety, Improving patient safety through governance and compliance and finally Bridging the gap: policy and clinical Practice. The human factors stream was chaired by Martin Bromiley OBE (@MartinBromiley) of medical “Just a routine operation” fame https://www.youtube.com/watch?v=JzlvgtPIof4 – if you don’t know who he is or his story as a healthcare professional then you really should so click on the youtube link and learn about it.
What is human factors?
As defined by NHS England Human Factors for healthcare are: “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”.
Essentially it is about
Making it easy to do the right thing
The stream started well and I very much enjoyed hearing from 3 speakers talking about how they had introduced human factors within their areas or work and outlining the importance of doing do. Dr Shelly Jeffcott (@drjeffcott) spoke first about the importance of human factors and outlined some goals.
She emphasised designing the systems so that it is easy to do the right thing and the importance of integrating human factors training in the medical workforce. Education for Scotland have developed an e-learning package on human factors. It is easy to create an account and access this at:
Next up in this session was Mr Simon Paterson-Brown (@spbsurgery) he spoke about the use of training within a surgical environment to develop non technical skills. His sessions Non-Technical Skills for Surgeons have international acclaim and have been widely published. Finally the session ended with Professor George Youngson (@ggyrach) whop focused on thE impact of bullying and discrimination in care systems. Bullying is a huge problem in the NHS and this was outlined during this session Professor Youngson identified that it is still a problem and has done work proving its detrimental effect on patient safety. He encouraged us to speak up for safety and ensure that bullying was addressed in our departments.
The stream then moved onto the nudge theory and how we can use this within the NHS.
Helping people to make the right decision at the right time thus improving patient safety. During this session there was talk about the noble prize winning book “Thinking fast and slow” by Daniel Kahneman looking at the way people make decisions and how the nudge theory exploits this. By understanding how people behave we can design better policies and systems to improve patient safety. The EAST framework was suggested here: Easy, Attractive, Social and Timely. Any change in behaviour should fit into this framework. And where there is variation in practice it offers a good target for change.
After lunch I remained in the Human Factors stream and the session delivered by Abbie Coutts and Professor Bryn Baxendale (@gasmanbax) focusing on situational awareness. During this session it was the first time in this conference that I was exposed to a patient story being used to demonstrate a learning point. This is something which was utilised through the conference, across many different streams and had a truly powerful impact. Abbie Coutts presented her father’s case and observations on why errors occurred.
She has used the errors in care which happened to her father to teach the health board which cared for him about human factors. She suggests that this should be taught by people doing the job and understand why errors happen in order to address them rather than just how they happened. Professor Bryn Baxendale then spoke about balancing acts and how to embedded key skills and behaviours into practice. Both speakers focused on normalising excellence and doing the simple things well.
The fourth session in the human factors stream again used a patient story presented by Kathryn Walton https://www.youtube.com/watch?v=r7gk1AvZKZA We heard from the patient, the healthcare worker and what happened afterwards. I would encourage everybody to follow the link about and listen to the story. This was an exceptionally emotive story and emphasised.
The final breakout session I attended was delivered by The GMC within the Driving a culture of patient safety stream who presented a discussion on the GMC survey and understanding this data in relation to patient safety. The keynote to end day one was delivered by Professor Alison Leary (@alisonleary1) and focused on the fact the “Hope is not a plan” and within medicine what we can learn from other safety critical industries. Professor Leary presented an the fact that the very structure of the NHS is significantly different to other safety critical industries in that we place our most junior inexperienced staff at the front line closest to the operational risk, with the experienced workforce behind the scenes. This is in contrast to other industries who use their experienced work force next to the operational risk and use them to allocate selected work to the junior teams. In the NHS we need to be focusing on rewarding frontline experts to stay where they are on the shop floors rather than moving them further and further away into managerial positions. We need to use good policy and education where the expectations are clear and safety is mandated alongside clear credible leadership. Her closing statement was particularly poignant and a quote from Dr Tracy Dillinger NASA “People defer to hope, but when failure is not an option, hope is not a plan”
We went out for dinner in Manchester as a group of leadership fellows and I can 100% recommend The Alchemist for cocktails because they are fantastic, and for those based in South Wales one has just opened in Cardiff (yay!).
Back to the conference ...!
Day 2 opened with the prize giving for the poster competition. I entered 2 posters and this one won its category of ‘Education and Training’ Proof that if you do an interesting improvement project then it’s always worth popping it into a conference because you never know how far it might go.
The keynotes opened with Dr Bill Kirkup presenting themes which happen when things go wrong and how we should use these to make sure that as organisations we do not get into situations where things go wrong. He identified the follow themes:
- Failure to learn
He ended with 5 key points for maintaining patient safety:
- Listen to the patient, they are telling you the answer
- Honesty not reputation management
- Investigate and learn – not suppressing bad news and learning from others mistakes
- Dismissing and denial leads to a slippery slope which is harder to stop
- Do NOT think “It will never happen here”
The second keynote was also focused on investigations but from the Healthcare Safety Investigation Branch and what we can learn from the investigations which they have already processed. It is worth reading the summary documents of these investigations as it is different from a root cause analysis which will take place internally. They look at the route cause but also ask “why?”
Again day 2 was split into streams. The 6 streams on day 2 were: Collaborating to achieve patient safety, Delivering improvement on the frontline, Using research to solve the big challenges, Prioritising safety for vulnerable people, workforce the crucial ingredient for safety and Bridging the gap: Policy and the clinical practice. I attended Leading from the top: New research on trust level leadership under the using research to solve the big challenges stream. I left this session feeling quite negative. The panel presented learning which they felt had happened since the Frances Report. Which seemed to be, in their opinions, very little. They appeared to feel that this was a continuing problem with variability in quality and consistency of leadership practises. I feel (esp. as a current leadership fellow) that the Wales deanery is actively promoting and encouraging learning about clinical leadership. And I would signpost anybody to the FMLM website if they want more information on clinical leadership. https://www.fmlm.ac.uk/
I then attended the LEDER program, http://www.bristol.ac.uk/sps/leder/, focusing on what needs to change for people with a learning disability in order to ensure their safety, under the Prioritising safety for vulnerable people. Again this focused on a patient story presenting the experience of the family of Oliver McGowan. (@PaulaMc007) They are campaigning for mandatory training for healthcare professional in how to adapt for patient with autism and learning difficulties. They want to work on preventing these stories and raise awareness for people to make reasonable adjustments. They encourage communication, an overriding theme from this year, with the patients, and their families as they know the patient best.
Then, before lunch I moved into the Workforce stream to hear from Leigh Kendall (@leighakendall) Again this presentation focused on a patient story presenting Hugo’s story focusing on preventable harm within a maternity setting. Hugo was born after Leigh suffered from HELLP syndrome at 24 week gestation and lived for 35 days. She is working on improving bereavement information and including bereaved families in the quality improvement processes, alongside communication between healthcare professionals. She again encouraged communication and stated something which will stick with me “You can’t upset us anymore because the worst has already happened” Don’t be afraid to speak to bereaved families they can give you vital information and want to have a voice. Mr Edward Morris then presented the work of the Royal College of Obstetricians and Gynaecologists on Each baby counts (@EachBabyCounts) again focusing on patient stories and human factors to encourage a focus on communication and preventing harm. https://www.rcog.org.uk/eachbabycounts
After lunch the conference was again brought back together for keynote sessions. The CQC Chief inspector of Hospitals, Professor Ted Baker, presented an evidence based argument for how Inspections can help us with patient safety. He encouraged us to engage and empower frontline staff to really focus on patient safety and put patients at the centre of what we do. He reminded us to “relentlessly focus on leadership and culture” but also to recognise that healthcare is a high risk area and we have to accept the implications of that fact. He believes that with backing the inspection process can be used to drive forward a culture of patient safety.
The Right Honourable Jeremy Hunt MP was due to present next in his role of Secretary of State for Health and Social care, but as he had been relocated and Matt Hancock (@MattHancock) had been in the job for less than 24 hours Professor Bruce Keogh and Dr Aidan Fowler from 1000 Lives stepped up to be part of a panel for the next steps for patient safety.
The conference closed hearing from a panel about how their organisations overcame safety challenges. The overriding themes were again all about culture, communication and mindset. If you can get this right then you seem to be on the right track!
The Patient Safety Congress was a fantastic, engaging conference and if you get a chance to go I really would. The use of patient stories to focus the attendees was a really useful tool and one which I will take forward with other presentations in the future. It was a really important reminder that we do have the opportunity even as trainees to focus on patient safety and improve outcomes.
Guest Blogger Dr Jordan Evans
N Engl J Med 2018;378:2275-87.
If there’s one thing we all know about manging diabetic ketoacidosis (DKA), it’s the importance of being extremely cautious with fluid management due to the risk of causing iatrogenic cerebral oedema right?...Wrong! Once again, like John Snow, we unfortunately ‘know nothing!’. When will the childhood lies end, Father Christmas isn’t real, the Easter bunny’s not real and now this, the most painful blow yet.
In this PECARN (Pediatric Emergency Care Applied Research Network) study, published in the New England Journal of Medicine, Nathan Kuppermann et al investigated the influence of intravenous fluid administered on the rates of neurological injury in children with DKA.
What was the reason for the study?
Brain injury occurs in the region of 0.5% - 1% of DKA presentations. It presents with sudden neurological deterioration. Patients without a marked neurological deterioration may have more mild neurological impairments e.g. memory / cognitive impairment. As all of us were likely taught, brain injury in DKA has long been thought to be iatrogenic, secondary to fluid administration causing cerebral oedema due to osmotic gradients. The evidence for this school of thought is however lacking and evidence has emerged actively disputing it. Alternative explanations have been proposed that there may be something about being particularly unwell with DKA that leads to the neurological injury, possibly inflammatory or vascular changes. The more unwell the patient is the more likely they are to require fluid resuscitation and therefore an association between severe DKA with brain injury and fluid administration could be mistaken as causation. Remember that association is not proof of causation! Oedema may develop secondary to the brain injury itself as it does in other mechanisms of injury such as trauma.
Where did the study take place?
The study was conducted across 13 centres in the United States.
Who did they include ?
Children aged 0 – 18 years with a diagnosis of DKA (pH < 7.25, glucose > 16.7 mmol/L. Children with GCS <12 were excluded two years into study (due to concerns of treating clinicians).
What did the investigators do?
Children presenting to study centres with DKA were randomly assigned to one of the following four groups;
1) 0.9% saline fast administration
2) 0.9% saline slow administration
3) 0.45% saline fast administration
4) 0.45% saline slow administration
The fast group were given a 20ml/kg bolus which was then followed with replacement of a 10% fluid deficit with the first half of the deficit volume being replaced over 12hrs and the rest over the next 24 hrs.
The slow group were given a 10ml/kg bolus which was then followed by replacement volume for a 5% deficit which was given over 48hrs.
The primary outcome was a decline in mental status (GCS <15 on two occasions within first 24 hours of treatment. Patients and parents were blinded but not the clinician.
Secondary outcomes; clinically apparent brain injury (neurological deterioration leading to clinical decision to treat for raised ICP, intubation or death), short term memory, memory & IQ at 2 months and 6 months.
What were the results?
4912 patients met the inclusion criteria. Due to the complexities of the study of these there were a total of 1389 episodes of DKA included in the study (from 1255 different children). There was a fall in GCS in 3.5% of these epsiodes (48 episodes). There was clinically apparent brain injury in 0.9% (12 episodes). There was no difference between the two groups for any of the outcomes. (Some of the raw results favoured the fast fluid administration group although none of these results reached a statistically significant level).
Kupperman et al. rightly concluded that ‘Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis’.
Take home message for practice in Wales
1. We no longer need to be as anxious about giving fluid too fast in DKA
2. If you need to give a bolus for shock do so without fear of causing cerebral oedema, this study provides evidence that it’s not harmful.
3. With regards to the fluid deficit replacement although this study shows we could safely give it a little faster stick to current practice of the Wales DKA protocol as it doesn’t show any improvement in outcomes for the faster administration of IV fluids.
4. It’s worth remembering that there is good evidence for using 0.9% saline for maintenance IV fluids in children (to prevent hyponatraemia) so it’s not clear why they chose to have arms in this trial with both 0.9% saline and 0.45% saline.
Dr Rebecca Broomfield