The Other Type of Swiss Cheese

There are a hundred ways I could begin this piece. I don’t know which is best. I have tossed the introduction up and around until it’s lost its sharp angry edges, but then it doesn’t lie down on the page the way I want it to. So I’ll just tell you the truth.

This morning, I dragged myself out for a ‘run’ (although having been at work until well past midnight last night, the word run is an exaggeration and a euphemism). Halfway through, I began to ruminate over the cases from my shift. One in particular. And the enormity of what I’d done, or more accurately had not, began to billow up in great technicolour emotion-drenched images. I stumbled a bit, then faltered, then after a few more hopeless steps, toppled to the ground, and, under the shade of a tree, sat bent over, and I wept. Heavy hot shaking tears, so that people walking by me holding onto the hands of their children looked away, and magpies (the avian Lannisters of this world) came sneaking close to see if they could pick anything from this strange beast. I cried with shame and a weary impotence. A low point, you may well agree.

I would like to tell you about this case. An elderly couple were involved in an MVA. The husband, who had been the driver, sustained a catastrophic brain injury, and although was intubated and the shell of him shipped alive up to ICU, his injury was deemed unsurvivable and it was anticipated he would die before nightfall ended. His wife, a delightful and legally blind quilt of a woman, was remarkably uninjured, but due to a persistent tachycardia, had a troponin measured, which was elevated. Beautiful progeny, from several generations, gathered by her bedside, holding her hand. She would be admitted to a high dependency trauma area. Of course, she wanted to visit husband before he died. She was sanguine, but determined. But here’s the catch of the story.

No one would take her up to ICU to do so. There were risks. There were rules. There were monitors. There were nursing ratios. There was the possibility that some minor event would occur, and who could begin to foresee the paperwork that would follow. There are guidelines. There are protocols. I, of course, as the duty consultant, fumed a bit. Said this is ridiculous, to a number of people, and insisted someone, somewhere, fix this ludicrous situation immediately. But what I didn’t do, was take her myself. Wheel her up, and sit with them in the quiet ping of those last ashen hours in the Unit.

I am deeply ashamed that I didn’t do it. Oh, excuses are easily found. I was, as it happened, incredibly tired (my day had begun at 0800, teaching registrars, then battling through this new OSCE system, a situation similar to being plonked by our College into a new country with a new language and an IKEA guidebook), then on shift as duty consultant (I have no need to find a metaphor to tell you how exhausting this is, my understanding readers), and this juncture, this possibility, occurred close to midnight, but, like all excuses, they are hollow and clanging; false recriminatory bells. I wanted to go home. I could barely think. But this was cold comfort the following morning, as I limped my way back home from the park, knowing I should have eschewed not only my own fatigue and that desire to absent myself from the department, but also the nonsense regulations and rules.

Which is the essence of this piece. Mostly I am an inveterate rule-breaker. I’ve been around for a while, and have seen hospital medicine morph and change (I will resist saying evolve, as this mostly implies change in a positive direction), and I don’t feel moved to conform to this aspect. We now have regulations and standards and guidelines and tickboxes and stickers and forms and clickboxes and schedules and tools and checks and clipboards. A lot of clipboards. These are designed to avoid the swiss cheese effect. Where systems fail and the holes line up and patients fall through the cracks. But what happens when the there are no holes at all, where the pieces of cheese are unbreachable, and nothing can get through? Even humanity shall not pass through. Is this more like a reverse swiss cheese effect? (Or perhaps a hard tasteless Edam?) That we are so constrained, at every turn, and every decision, that the vital ingredient, the infinite complexity of human decision-making is lost?

Without argument, medical errors need to be prevented. Absolutely. But there must be ways to achieve this without stamping out every random action of humanity, smothered as they are by algorithms and checkboxes. Hospitals are drowning in middle management and rules – these layers and layers of people and their forms separating what in essence is unique individual human interaction – the heart of what we do.

This man died last night without his wife being at his side. I do not blame anybody but myself, hence the pathetic weeping woman at the base of a lonely tree this morning. It was my failure. But every time rules and guidelines and regulations are enforced without any regard for their impact on the simple unit of care we provide, that is, the interaction between one human and another, then circumstances like this will occur again. To put two clichés in a blender, swiss cheese is meant to be broken. A few holes here and there mean we’ve still got hope in medicine. And it is up to us, as individuals, to keep the individuality in there, the heart of medicine.