Can you imagine dying of thirst?
In case you have difficulty, here’s a brief extract from Daniel Philbrick’s 2001 excellent book “In the Heart of the Sea“:
[in] the “cotton-mouth” phase of thirst. Saliva becomes thick and foul-tasting; the tongue clings irritatingly to the teeth and the roof of the mouth. Even though speech is difficult sufferers are often moved to complain ceaselessly about their thirst until their voices become so cracked and hoarse that they can speak no more. A lump seems to form in the throat, causing the sufferer to swallow repeatedly in a vain attempt to dislodge it. Severe pain is felt in the head and neck. The face feels full due to the shrinking of the skin. Hearing is affected, and many people begin to hallucinate.
There’s more – which I’ll spare you. This is not something you’d expect to experience anywhere except by misadventure in the desert or after a shipwreck.
Sadly though, an NHS patient had exactly that experience in 2009 – purely because the people charged with his care in hospital were deaf to his pleas for water. Click here for the news reports on the inquest into Kane Gorny.
The question for all of us involved in improving hospital care is this: How can we prevent such tragedies happening in our organisations. The hospital in which this occurred is a world-class organisation – such tragedies probably do occur on a small scale in our own organisations too.
A straightforward answer is to agree behavioural guidelines across the hospital and for each department (see Chapter 7 of the Meaning of Careful for more detail)
Here’s a simple example that I promote with junior staff – but which is general enough to use in any clincial environment. This is “Practical Compassion”, based on an ABCDE mnemonic.
In case you have difficulty, here’s a brief extract from Daniel Philbrick’s 2001 excellent book “In the Heart of the Sea“:
[in] the “cotton-mouth” phase of thirst. Saliva becomes thick and foul-tasting; the tongue clings irritatingly to the teeth and the roof of the mouth. Even though speech is difficult sufferers are often moved to complain ceaselessly about their thirst until their voices become so cracked and hoarse that they can speak no more. A lump seems to form in the throat, causing the sufferer to swallow repeatedly in a vain attempt to dislodge it. Severe pain is felt in the head and neck. The face feels full due to the shrinking of the skin. Hearing is affected, and many people begin to hallucinate.
There’s more – which I’ll spare you. This is not something you’d expect to experience anywhere except by misadventure in the desert or after a shipwreck.
Sadly though, an NHS patient had exactly that experience in 2009 – purely because the people charged with his care in hospital were deaf to his pleas for water. Click here for the news reports on the inquest into Kane Gorny.
The question for all of us involved in improving hospital care is this: How can we prevent such tragedies happening in our organisations. The hospital in which this occurred is a world-class organisation – such tragedies probably do occur on a small scale in our own organisations too.
A straightforward answer is to agree behavioural guidelines across the hospital and for each department (see Chapter 7 of the Meaning of Careful for more detail)
Here’s a simple example that I promote with junior staff – but which is general enough to use in any clincial environment. This is “Practical Compassion”, based on an ABCDE mnemonic.
Click for PDF Would these principles have saved Kane’s life. Answer: yes. Here’s why.
1) A = Always Ask: If any of the nurses or doctors had sought outside help (perhaps from a medical team, since he was a surgical patient) he might have stood a chance.
2) B = Be Benign: If anyone had actually believed that he was thirsty – rather than believing him to be a trouble-maker – then something would have been done.
3) C = Consider Catastrophe: what was the worst case situation here? Had anyone considered that his distress might have been caused by something serious? Clearly not.
4) D = Document Diligently: were the notes concise and well kept. According to his mother, the notes were so thick that no one bothered to read them. If they had, they would have spotted his DI.
5) E = Explain everything: did staff talk, in everyday language, to Kane and his family? I am left to wonder.
If you like the poster, please download it and use it – and modify it, as you see fit for your own area.
1) A = Always Ask: If any of the nurses or doctors had sought outside help (perhaps from a medical team, since he was a surgical patient) he might have stood a chance.
2) B = Be Benign: If anyone had actually believed that he was thirsty – rather than believing him to be a trouble-maker – then something would have been done.
3) C = Consider Catastrophe: what was the worst case situation here? Had anyone considered that his distress might have been caused by something serious? Clearly not.
4) D = Document Diligently: were the notes concise and well kept. According to his mother, the notes were so thick that no one bothered to read them. If they had, they would have spotted his DI.
5) E = Explain everything: did staff talk, in everyday language, to Kane and his family? I am left to wonder.
If you like the poster, please download it and use it – and modify it, as you see fit for your own area.
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