Getting the Priorities Right

06 Apr 2020

Published 06 April 2020

The TJTO&C is gaining its own identity. There wasn’t a great strategic plan at its initiation beyond creating a readily accessible forum and hoping that words would flow. Thankfully this has been rewarded by a wide variety of submissions.

In the first editorial I referred to the Hitchhikers Guide to the Galaxy, whilst possibly a little light-hearted for our current dilemma I still believe the Book has something to offer. ‘Don’t Panic’ were the words on its front cover and I borrowed them to put alongside the title of the TJTO&C. At the time it seemed ‘neat’ just as in the Book, but I continue to think it appropriate. One of the consequences of emotion interfering with decision making is a tendency to either freeze or go off into random undirected actions. Whichever happens the result is a cessation of useful activity.

How do we address or pre-empt difficult situations? We think, argue, reflect, plan and then write endless guidelines, protocols, codes, advice sheets etc, etc, etc; we have a lot of these. But, we know better than that. Some years ago Atol Gawande wrote the Checklist Manifesto and documented the thought behind and the rise of the WHO checklist; it is a brilliant book. In it there are extensive references to checklists in other walks of life. Should you be building a multi-storey office block, a highly detailed itemised checklist is necessary to ensure smooth satisfactory progress. For instance, specifying order of actions; the cooling system on floor 26 is to be installed before the walls so that you can actually get in. This is a methodical approach in a controlled environment suited to a clipboard bearing obsessive. However, the checklist to help us when things are rapidly going wrong needs to be quite different. Just a few items, Gawande suggests four or five, not to cover every detail but just aimed at resolving the situation. Taking the example of that for pilots he notes that the checklist does not itself fly the plane, you (the pilot) have to keep doing that. So the number one item on their checklist is advice not to neglect flying the plane.

Based upon this I believe there is an equivalent for a health service, I suggest:

  1. Keep treating patients
  2. Decide which patients to treat
  3. Assess / increase resources
  4. Repeat cycle

Whilst the checklist itself must brief the explanatory notes are allowed to be longer. So why ‘Keep treating patients’ as the first line? This is first as there is otherwise the risk of freezing or being distracted, the result being that treating patients stops. Whilst some people should be doing the thinking the rest of us should be doing the doing; and initially that doing can be relatively close to normal. In the current crisis many places are now beyond this but by no means all.

Whilst observing point 1 we can initiate point 2. We should now consider which patients we should treat. In the current crisis there can be a momentum either planned or unconsciously evolved to concentrate solely on the COVID-19 patients. We all want to do our bit for the huge effort to manage those of us unfortunate enough to become patients requiring hospitalisation with that disease. However, that should not obscure a proper global discussion of which patients to treat. Heart attacks, strokes, triple A’s, hip fractures etc will continue to occur and deserve a balanced consideration for their care alongside the COVID-19 patients. There are difficult comparisons to make, but with finite resources they must be made. Currently the most precious resources for surgical patients are a theatre and an anaesthetist. Using a theatre to ventilate one or two patients for 14 days has to be weighed against the societal benefit of 14 days of time critical surgery being carried out.

Point 3 is to concentrate the mind on having full knowledge of and addressing shortfalls in resource. Having done that, just like we were all taught in ATLS go back to the beginning and make sure we keep treating patients. The objective is surely that at the end of this crisis we will be able to look back and believe that we did our best to treat to best effect the maximum number of patients be their major problem COVID-19, heart attack, stroke, triple A or hip fracture. We don’t want to look back and see that despite all efforts when we look at the whole patient population that there was unnecessary morbidity and mortality in the non-COVID-19 groups.

The national effort is quite rightly motivated by the needs of the COVID-19 patients. The national emotional response is naturally focussed on these patients and we risk being swept along with this to the extent that professional judgement is skewed. However, we have a duty to provide the best overall outcome the circumstances allow considering all patients. For T&O this translates to two obvious tactics firstly not treating patients unnecessarily, and secondly when treatment is required carrying it out with minimum impact on the rest of the service. However, there is a final point that for our time critical patients we must be their advocates to secure for them neither more nor less of the resources than they merit. For our patients the pinch point is theatre and anaesthetics. As a surgical discipline we need to be involved not just at the beginning of an individual day assessing priorities within the resource we are given for the next 12 hours, but strategically in the allocation of those resources. Whilst difficult triage decisions may unavoidable for some locations and for some periods, we should not accept them as a new norm. Whilst all doctors should be prepared to stand up for all patients, there is no doubt that in each speciality we should continue to be for advocates for those we know best.

Keep safe.

Bob Handley

Contributions should be sent to jto@boa.ac.uk with the subject line: TJTO&C.

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