Saving lives

About Health –

Dr Atul Gawande’s simple one-page checklist aims to cut deaths from surgery

When the US military researched ways to lower the amount of soldiers being blinded in combat, the solution was not what many had expected.

They found it difficult to understand why, when soldiers were already provided with adequate protection goggles, there were still a high number of eye-related injuries.

It turned out the problem was obvious: the goggles made them look – in their words – "like grannies".

Soldiers were issued with some new, cooler goggles created by designer Wiley X.

Now they wear them all the time – even when they don’t need to.

As a result, there has been a tremendous drop in the numbers of soldiers blinded in battle.

It’s just one example which symbolises the philosophy of Dr Atul Gawande, associate professor at Harvard Medical School.

Dr Gawande – who is also a writer for New Yorker magazine, and author of the best-selling medical books Complications and Better – believes that the biggest challenge in medicine isn’t discovery, but implementation.

His newest book, The Checklist Manifesto, looks to explain how simply applying well-known knowledge efficiently can make the biggest change when trying to save lives.

Biggest struggle

Dr Gawande spoke to Claudia Hammond on BBC World Service’s Health Check programme about his work.

"For the longest time our biggest struggle was ignorance. It was knowing what do we possibly do about illness – how do we understand it?

"But now we’ve accumulated 6,000 drugs and 4,000 different kinds of medical and surgical procedures.

When people get a chance to say their name out loud, it actually changes the likelihood that they will speak up later when they have a problem or have any doubts. Dr Atul Gawande

"What we’re actually learning is that equally hard is the deployment of treatment."

This approach was seen to full effect when Dr Gawande was in India to witness the monumental effort to vaccinate four million children in just three days.

It was the first case of the disease in over two years, which kicked off when a family travelled down from the north.

The scale of the response was barely imaginable. Every child within a 50,000 mile radius had to receive the vaccine.

"On the one level," Dr Gawande says. "You think solving the polio problem is about just making sure people get an injection. How hard can that be?"

"So we’ve invested all of our effort in the early part of the last century in discovering the solution – but not in thinking about how do you actually deploy it."

Seeing the vaccination programme take off was like watching an army get into gear, Dr Gawande remembers.

"You think it is impossible. They had to go door-to-door."

The teams used the knowledge of local physicians who had studied the area to assess logistical challenges – such as making sure ice could be transported with the vaccines to keep them at the correct temperature.

The Checklist Manifesto

Dr Gawande expertise was put to use when the WHO aimed to cut deaths from surgery around the world.

There are now, Dr Gawande noted, more operations worldwide than there are child deliveries – but the death rates are much higher.

Taking inspiration from the checklist used by pilots before they take off, Dr Gawande worked on producing a checklist for safer surgery.

"There were basic things that if we were much more consistent about it could actually save lives.

"There are steps like ‘make sure an antibiotic is given, make sure blood is available for a risky case’, but then there are also components that had to do with having a team of people that could execute well."

Indeed, many of the key points in the checklist are more personal than medical, such as spending time before an operating team to allow each member of a team to speak up and introduce themselves.

"There’s tremendous hierarchy in an operating room, and when people get a chance to say their name out loud, it actually changes the likelihood that they will speak up later when they have a problem or have any doubts."

The checklist has been used in eight countries, including hospitals in Jordan, the Philippines and Tanzania and India.

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In the UK, research by the National Patient Safety Agency released last year showed that using the checklist can cut surgery-related death by up to 40% – and there are plans to make the checklist compulsory in hospitals in England and Wales by February 2010.

Dr Sudhir Joseph is the director of St. Stephen’s Hospital in Delhi – where the checklist is now being used.

"Quite frankly, when I heard about this, I was wondering as to the true efficacy of this, whether it was just too basic a tool," he told the BBC’s Nivedita Pathak.

"At the same time, however, I was a little concerned because we did not have a proper comprehensive checklist for people coming in."

The checklist has seen the hospital introduce a tagging scheme to prevent operating on the ‘wrong side’ – that is the mistake of, for example, operating on a right foot when the issue is with the left.

Dr Joseph says time will tell if the checklist has any long term benefits for hospitals like St Stephen’s.

The bigger picture

As the checklist filters through health care systems across the world, Dr Gawande looks to an instance in India, during the vaccination efforts, to remind him of the bigger picture.

"When we walked through one village a mother came out who had a child.

HEALTH CHECK Health Check is the weekly health programme broadcast from the BBC World Service It is broadcast on Monday at 1032GMT and repeated at 1532GMT, 2032GMT and on Tuesday at 0132GMT It is also available as a podcast

"The mother did not want to take the vaccine. I was with the WHO doctor who simply said, ‘That’s fine.’

"One of the local physicians then started screaming at the mother, ‘How can you not take this vaccine?’."

"And then the WHO doctor came back and he started yelling in anger. Not at the mother – at the local doctor.

"Saying, ‘you are endangering our entire programme here. If we force them to take the polio vaccine we’ll spread the word that it’s being forced upon the community and the whole effort will die. One person may slip through – but if we get this community, that’s what we’ve solved.’"

About Health – Saving lives

About Health –

Thirteen young people have been detected with serious heart defects during a charity screening tour.

More than 2,000 young people in England have had their hearts tested for abnormalities that could lead to Sudden Death Syndrome.

It is a condition that affects apparently healthy and fit 14-35 year olds, killing 12 in the UK every week.

Charity CRY (Cardiac Risk in the Young) has toured the country, offering free tests and raising awareness.

Four of the 13 young people positively diagnosed were found to be at very high risk.

The young people and their parents are now going through various stages of counselling whilst working out what sort of lifestyle changes, medication and in some cases, what surgery they need.

Dr Papadakis says the tour has potentially saved lives

Dr Michael Papadakis, a cardiologist working for the charity, said the tour – carried out in conjunction with healthcare company Philips- had been a success.

He said: "We have identified 13 young people who have heart problems and we have potentially saved their lives."

There are a whole range of heart defects that can lead to Sudden Death Syndrome.

Andy Scott, manager of Brentford Football Club, knows all too well what it is like to live with a positive diagnosis.

"I was playing at Leyton Orient at the time," he said.

"Half way through the game at Cheltenham on Good Friday, I started to feel awful.

"I had chest pains, pins and needles and I was struggling to breathe.

"I came off the pitch and told the manager I couldn’t go on."

Warning signs

That was back in 2005. Since then Andy has been diagnosed with hypertrophic cardiomyopathy.

It is the same heart condition Cameroon footballer Marc-Vivien Foe died of during the middle of an international game in 2003.

As we sit here now, someone is having to face the same sort of struggle we’ve had to face Paul Clabburn

But, unlike the midfielder, Andy displayed warning symptoms which effectively saved his life.

"I was 32 and that was it for me," he said. "I had to stop playing football or else it would kill me.

"There are so many emotions you go though.

"These young people will be thinking, ‘why me?’ But it’s much better to know about these things and have a life in front of you rather than your family having to deal with the consequences."

Andy knew he could no longer be a footballer but still wanted to be involved in the game.

He eventually became the Manager of Brentford football Club but still has to stay away from doing any extreme exercise.

Screening is critical

The only way to find out if you are at risk of Sudden Death Syndrome is through screening.

Tom Clabburn died suddenly in bed

Most people, like Paul Clabburn’s son, Tom, do not show any symptoms at all.

He died in his bed when he was just 14 years old, weeks before his 15th birthday.

"Tom was a normal healthy boy. He loved playing football. He loved playing tennis," said Paul.

"He showed no signs of any major illness so it was a complete shock to us he was suffering from a heart condition."

Paul and his wife, Claire Prosser, now support the work CRY does.

The final stop of the charity’s first free testing tour took place at Brentford football Club in Tom’s memory.

Sudden Death Syndrome, if detected, is preventable and treatable.

But at the moment screening for the condition is not freely available on the NHS.

It costs around £100 to get it done privately or CRY offer tests at a subsidised cost of £35.

Mandatory testing

In Italy, Electrocardiogram (ECG) screening is now mandatory in children from the age of 13 if they take part in competitive sport.

And Cry wants a similar thing to be available on the NHS.

A Department of Health spokesperson said: "The UK National Screening Committee has always concluded that there is not enough evidence to warrant either a blanket-screening programme or one targeted specifically at those groups thought to be at high risk like young athletes.

"If the condition is detected in a person, it may never affect them.

"Also, if that person is involved in sporting activities, there is little evidence to suggest that removing them from that physical environment will actually reduce or increase their risk of dying suddenly from the condition."

But Paul said it would be the only way to stop families like his, having to go through the death of a child.

"There are twelve deaths a week. That’s more than one a day," he said.

"As we sit here now, someone is having to face the same sort of struggle we’ve had to face."

About Health – Saving lives

About Health –

It was a normal newsroom morning when I took the call from Dr Peter Wilde to get to his cath labs at the Bristol Royal Infirmary straight away.

“We have a 36-year-old man with a suspected heart attack coming in by ambulance and he should arrive in 20 minutes,” the medical director told me.

I managed to arrive in the corridor with my small camera just before John Truckle, from Clevedon, was wheeled down into a waiting bay.

Mr Truckle kindly allowed my unique access to film the primary angioplasty that was to save his life.

The procedure is used to unblock an artery carrying blood to the heart under a local anaesthetic.

It was John’s wife, Claire, who called for the ambulance after the father of two complained of sharp stabbing pains in his chest and feeling clammy.

The irony is that John was himself due to be working in a hospital setting today, as a lighting engineer on the BBC Casualty set.

Like other cardiac attack patients, doctors had to get Mr Truckle on the operating table within two hours of the alarm being raised.

In the operating theatre some dye was injected into John’s heart to locate the blockage.

Even for my untrained eye, it was easy to see where the blood flow has come to a complete stop on the CT scan screen.

Safer option

Until now the preferred treatment for heart attacks was to give injections of clot-busting drugs. But in up to half of patients the drugs do not work.

Professor Boyle is concerned about access in some areas

So for patients like John, primary angioplasty is the safer option.

A wire was inserted into John’s wrist to take it up through a blood vessel into his heart to physically pull the clot out.

John was awake throughout the procedure, as he was under local anaesthetic.

It was just as well, because for one nerve-tingling moment his heart went into cardiac arrhythmia as the blood clot was cleared form his artery.

Dr Wilde told him to cough to kick start the organ into normal function.

Forty minutes after John came in, and the procedure was finished.

Big expansion

The Department of Health want 97% of heart attack patients to be offered primary angioplasty by October 2011.

The government’s heart Czar is in talks with air ambulance services to try to ensure all heart attack patients in England have access to the new operation.

At present, it is only available to a quarter of patients – but the government wants it to be an option for everyone within three years.

Research has shown that heart attack patients have a 5.6% risk of death within the next 30 days if they receive primary angioplasty quickly.

For those treated with clot busting drugs, there is a 7.9% risk.

This equates to around 240 lives which could be saved in England every year – and 260 strokes.

To try to make this aim a reality, cardiac centres around the country are trying to agree a new model of care to fit the plan devised by Professor Roger Boyle, the government’s national clinical director for heart disease and strokes.

The Bristol Heart Institute is one of several centres across England reaching agreements with neighbouring cardiologists to work an overnight shift at the centre, so that this new operation can be offered 24 hours a day.

Speed vital

Because it needs to be done very quickly, specialists have to be able to operate at a moment’s notice and the patient has to be whisked straight to them by the ambulance.

But Professor Boyle said there were some rural areas, such as the Lincolnshire coast, Cumbria, Shropshire, Herefordshire and Cornwall and North Devon where it will be difficult to have a similar 24/7 model.

He believes the ultimate solution for those areas is air ambulances.

Professor Boyle said: “The problem with air ambulance is that most don’t fly at night and there are also concerns about the cost.

“Ultimately that is the solution, but there is quite a lot of work to do before we can get the building blocks in place.

“We are working with ambulance services. The costs for air ambulance are quite considerable as they won’t have more journeys to do, but longer journeys.”

About Health – Saving lives

About Health –

The new crash trolley design could save lives, say its designers

When a patient’s heart stops beating, there is no time for delays and confusion.

Hospital are well drilled for this kind of emergency and staff know exactly who should be doing what.

But there are claims that a simple design fault could be putting lives at risk.

For the last 60 years the design of the resuscitation “crash” trolley, which contains all equipment and drugs needed for cardiopulmonary resuscitation – needed when someone’s heart or breathing stops – and for emergency care has not changed.

Easier to use

Medics and safety experts agree the situation is less than ideal and warn that the current trolley’s layout is confusing and dangerous – and that vital equipment is often missing.

Now, after calls from the National Patient Safety Agency (NPSA), a group of designers and doctors, have come up with a new trolley that they believe will help save lives.

It is laid out in a more intuitive way so that you have everything you need first at the top and subsequent things lower down Jonathan West

As well as alerting medics when equipment is out-of-date or missing, the trolley also splits into three sections so that equipment can be used in the order needed and by separate groups working on the patient.

Kit is separated depending on whether it is needed to clear an airway, gain intravenous access to give fluids and drugs and defibrillation equipment to restart the heart.

‘Intuitive and simple’

Dr James Kinross, from St Mary’s Hospital, part of Imperial College Healthcare NHS Trust, who helped with the trolley design, said an overhaul was long overdue.

“Remarkably the design is still based on a garage tool trolley,” he said.

“Doctors and nurses work together under stressful and time critical conditions to resuscitate patients who have suffered a cardio-respiratory arrest.

The trolley splits into three sections so that equipment can be used in order

“But data suggests that poor design of crash trolleys may directly influence the risk of an adverse event for the patient, preventing a successful resuscitation attempt.

“The design solutions are intuitive and simple so that any member of a team can use the trolley without instruction.

“For example, the trolley has no drawers and all medical equipment is highly visible and easy to locate in an emergency.”

Designer Jonathan West from the Helen Hamlyn Centre, part of the Royal College of Art, and fellow designer Sally Halls, said the new trolley is set to start trials at St Mary’s.

Mr West said: “The trolleys are basically tall with metal and closed drawers.

“The problem with the existing model is that everything is stowed away.

“Not being to see all the equipment might mean that you take a while to find all the kit you need

“You never seem to have everything you need, which is why we have laid everything out openly.

“It is also laid out in a more intuitive way so that you have everything you need first at the top and subsequent things lower down.”

Award winner

The design has won two Medical Futures Innovation Awards. It was also shortlisted for Best National Health Innovation, and the Anaesthesia and Critical Care Innovation Awards.

David Cousins, head of safer medication and medical specialties at the NPSA said the new design could make a big difference.

“Incidents reported to the NPSA showed that resuscitation trolleys were not always stocked with all the necessary equipment and medicines and sometimes medicines had passed their expiry date.

“These incidents demonstrated the need for a re-design of the trolleys in order to help improve patient safety.

“We fully support this redesign by the Helen Hamlyn Centre and look forward to seeing the benefits of the trial and roll out.”