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Complication ??? Breaking the news !!!. G N Ramesh PVS Memorial Hospital Kochi. Complications happen …… to every one. The busier you are …… the higher the risk A good endoscopist …. does many ..... gets away w ith it.

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Complication breaking the news

Complication ???Breaking the news !!!

G N Ramesh

PVS Memorial Hospital

Kochi


Complications happen …… to every one.

The busier you are …… the higher the risk

A good endoscopist …. does many ..... gets away

with it.

A professional one …. does many …. May have the odd complication … handles the aftermath with calm, assurance and common sense.


Complications in gi endoscopy
Complications in GI endoscopy

  • The challenge….to keep it to the minimum

  • The science……effective management

  • The ultimate trial….. To deal with complications at a personal, psychological and social level .


“ Don’t read stories of success

Read stories of failures.

Success stories give messages

Stories of failures give new ideas to win ”




‘ If you deserve to blossom like a rose in the garden,

you have to learn the art of adjusting with the thorns ’

- Anonymous


What could go wrong
What could go wrong ?

  • Desired result not achieved

  • Co morbid illness related event

  • Bleed


What could go wrong1
What could go wrong ?

  • Desired result not achieved

  • Co morbid illness related event

  • Bleed

  • Perforation

  • Cardiac arrest on table

  • Colleague related event

The worst !!!


Situation ….Saturday afternoon

68 year old thin lady

screening colonoscopy

5th on a list of 6 cases.

all bags packed….ready to go.

prep took a little while longer…

finally clear at 3 pm.

difficult sigmoid………..hell!!!


Then the recap starts
Then the recap starts……..

  • Did I need to do it ?

  • What have I told them ?

  • Was the consent form signed ?

  • Who must have signed ?

  • Do I know any one of them ?

  • Were the risks explained ?


Then the recap starts1
Then the recap starts……..

  • Did I need to do it ? Maybe not!!!

  • What have I told them ? Nothing!!!

  • Was the consent form signed ???

  • Who must have signed ? Don’t know !!!

  • Do I know any one of them ? No!!!

  • Were the risks explained ? Not exactly !!!


Then the recap starts2
Then the recap starts……..

  • Did I need to do it ?

  • What have I told them ?

  • Was the consent form signed ?

  • Who must have signed ?

  • Do I know any one of them ?

  • Were the risks explained ?

  • Whom should I talk to ?

  • What next ?

  • What about the expenses ?


Then finally
Then finally……..

  • And……….. What about my bags ???


The first feeling
The first feeling

‘ I just wish I were somewhere else ….. I don’t care where it is, I just don’t want to be here now facing this patient and their family, telling them these bad things have happened’

- John L Petrini .MD.

President , ASGE



Cocktail of emotions
Cocktail of emotions

  • Guilt

  • Frustration

  • Remorse

  • Sympathy

  • Panic

  • Confusion………………


Basic 2 questions
Basic 2 questions

  • How should I maintain/ repair my relationship with the patient/ relatives ?

  • How do I keep from getting sued ?


The realisation
The realisation…..

  • Complications are an anticipated part of procedures.

  • It is how you face them (as much as how you avoid them) that defines your character as a professional.

  • It is also about planning and preparedness


Don t think that the world is going to end don t try the escapist route deal with it head on

Don’t think that the world is going to end!!!Don’t try the escapist route !!!Deal with it head – on .



Avoiding complications
Avoiding Complications

Just Stay out of the way !


Avoiding complications1
Avoiding complications

‘not being in the wrong place at the wrong time”


You’ll never be BRAVE if you don’t get hurt

You’ll never LEARN if you don’t make mistakes

You’ll never be SUCCESSFUL if you don’t encounter failure



Breaking news of a complication
Breaking news of a complication

  • What can make it easier?

  • The essentials

  • The do’s

  • The don’ts



3 steps
3 steps

  • Preprocedure Explanation/Informed consent

  • Post procedure communications

  • Being present and in control


Pre procedure explanations
Pre-Procedure Explanations

  • No procedure is “ a piece of cake ”

  • Packaging of the ‘ flip side ’

  • Take relatives into confidence

  • Not demeaning to inform possible complications


The e m b r a c e format
The E M B R A C E format

  • A full Explanation of the procedure

  • The Motivation(reasoning) behind the medical recommendations

  • The Benefits from undergoing the procedure

  • The Risks involved

  • What Alternatives are available(including doing nothing)

  • What Complications may occur ( including their frequency)

  • Any possible side Effects


The informed consent will take care of 80% of the problem.The rest of the story unfolds after the complication …and you are the lead character!!!


The 3 golden rules
The 3 golden rules

The consent

Communication

Rapport



Breaking the news of a complication

Breaking the news of a complication……

Is an art , nothing very scientific about it!!!



“ Life’s challenges are not supposed to paralyse you, they’re supposed to help you discover who you are ”


The facts
The facts they’re supposed to help you discover who you are ”

  • Most endoscopists don’t know how to handle complications beyond the procedural nuts and bolts

  • No forum for discussion


“ Doctors are wonderful. Up until the last few years, unfortunately they received virtually no training in medical school on how to communicate bad outcomes to patients ”

“ They are taught everything under the sun clinically and academically, but nobody teaches them the softer side of medicine ”

David Sousa, Sr. VP,

Medical Mutual Insurance Company of

North Carolina


“ When complications or adverse events occur, it is critical that physicians are honest with themselves and with their patients ….. that they acknowledge the possibility that an adverse event has occurred ……. And communicate these concerns in a timely fashion and with complete truthfulness to patients and their families ”


“ When complications or adverse events occur, it is critical that physicians are honest with themselves and with their patients …..

that they acknowledge the possibility that an adverse event has occurred …….

And communicate these concerns in a timely fashion and with complete truthfulness to patients and their families ”


Post complication communications
Post complication communications critical that physicians are

  • Choose a comfortable briefing area

  • 2-3 relatives ( close ones )

  • Offer undiluted , undivided attention

  • Be calm yet assertive and reassuring


Post complication communication
Post complication communication critical that physicians are

Be transparent:

  • Talk about the procedure, risks, your intended aims, and what happened

  • Express empathy and apologize without implying blame/ malpractice

  • Tell them what you intend to do


Post procedure communications
Post-Procedure Communications critical that physicians are

Be there and be in control!!!

  • Get the team together

  • Surgeon/ Intensivist/ Cardiologist/ Physician

  • Make sure the patient is being attended to

  • Arrange to shift patient to intensive care


No one will ask you why it happened!! critical that physicians are

You will be judged by what you do in the aftermath

By the clarity of your thoughts and communication

By your sincerity and empathy

THE RESPONSIBLE RESPONSE!!!


Manage the relatives critical that physicians are

Manage the patient

Manage yourselves

Manage the records

Risk of litigation


If you wrote it , you did, critical that physicians are

If you didn’t , you had it !!!

Manage the relatives

Manage the patient

Manage yourselves

Manage the records

Risk of litigation


Reactions
Reactions critical that physicians are

  • Some patients will want a lot of contact/empathy.

  • Some will be satisfied with an apology, and a reassurance/ assurance

  • The inquisitive/ probing patient/ relatives

  • Anger/ threats


Anger threats
Anger/ Threats critical that physicians are

  • Don’t loose cool

  • Inform your team

  • Inform the management

  • Don’t abandon

  • Keep communicating with the people


Angry relatives – short term crisis critical that physicians are

Quiet relatives - dangerous


The do s
The Do’s critical that physicians are

  • Sit down….calm yourselves..get thoughts together

  • Write / Document

  • Involve …..surgeon/intensivist

  • Plan

  • Empathise….Communicate…………..communicate….Listen


The don ts
The Don’ts critical that physicians are

  • Don’t transfer ownership

  • Don’t delegate communication

  • Don’t be defensive

  • Don’t be arrogant

  • Don’t cover up



Medicine is not now, and never has been, an exact science. Despite the exercise of the greatest skill, things can go wrong


Thank you

Thank you Despite the exercise of the greatest skill, things can go wrong


Complications of endoscopy summary
Complications of Endoscopy Despite the exercise of the greatest skill, things can go wrongSummary

  • know limits

  • recognize promptly

  • deal ‘head on’

  • early, appropriate management

  • communicate

  • keep channel open

  • seek help and opinion


The bottom lines
The bottom lines: Despite the exercise of the greatest skill, things can go wrong

  • Establish rapport ( patient and family )

  • Show warmth and compassion

  • No procedure is too simple !

  • Express empathy, compassion and confidence

  • Don’t assume litigation … but take precautions

  • Careful and complete records


The biggest problems
The biggest problems Despite the exercise of the greatest skill, things can go wrong

  • Inadequate pre-procedure preparation

  • The consent

  • The guilt that follows

  • Tendency to deny / escape

  • Enemies within

  • Lack of communication

  • Crazy documentation


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