Podcast – Excellence in Debriefing with Richard Lyon at LTC

Welcome to the St Emlyn’s Podcast. I’m Iain Beardsell.

 And I’m Natalie May.

And we’re at the London Trauma Conference 2024 in beautiful Kensington.

And delighted to welcome Richard Lyon who’s going to give us a little bit of a background to the talk he’s given at the conference. And we’re going to delve a bit deeper into some of his thoughts. But Richard, before we start, do you mind just introducing yourself to our listeners?

 Thanks Iain. good to see you and thanks Natalie for having me on the podcast. My name’s Richard. I’m an emergency doctor, slightly crazy life in that I live and work in A& E in Edinburgh. And I’m also the deputy medical director of the air ambulance service at Kent, Surrey and Sussex and spend an awful lot of time on Easy Jet zooming up and down between the two.

And you gave us a really powerful talk yesterday with some learning from five cases that you said it shaped you as a clinician and as a human, and I wanted us to talk a little bit more about that. We do a lot of learning at Sydney Hems from our own cases and our informal coughing cases. How powerful do you find that in your practice and how do you think we can do that safely and effectively as clinicians?

It’s a great question, Natalie. And I think in the HEMS world, we are very used to case debriefing. We have the D&D process, you think back to the D&D shed on the London HEMS pad where the vast majority of prehospital cases were reviewed, in significant detail. And I think about my hospital practice as very different. One or two cases might make it to the monthly M and M meeting, and we don’t go into nearly the same level of detail and case reflection and how we could do better.

And I think that’s just in terms of a kind of a clinical practice. What I was speaking about yesterday was, there are also those sentinel cases that really shape who we are as clinicians and human beings and those cases, don’t get nearly enough airtime and learning time, and I think we could probably all do a bit better on that front.

Do you think there are challenges for us personally as well around case learning? Because I know some of the cases that you talked about had obviously very deeply affected you, and you can even detect that effect within the audience. How can we navigate our way through that?

It’s really important to think about. the process of case learning, and I think sometimes just self-reflection is enough.

Those cases where you can just take time, you can think about the case, it’s helpful, obviously, if you know the outcome. You might talk about the case with say the paramedic that did the job with you, and we have a coffee and cases session on base and just sometimes that kind of low-level reflection is enough.

I think moving up to the more complex cases, particularly when you’ve got a case where, something hasn’t gone well or, an adverse incident has happened or it’s just a bit more meaty, you probably need some sort of case facilitator. And then having access to that case facilitator is quite important because it’s got to be someone that is senior enough to understand the medicine and understand what should have happened or what optimum care would have looked like.

But that individual also needs to be the right individual to guide the team through the debrief in a kind of supportive, constructive way, to make sure we get the right outcome. And often these cases might be debriefed in a kind of group setting, if we think about our governance days where the wider team might be present, and you need to think about the impact that the case is going to have on the wider team.

And of course, It’s important the wider team hear about them for learning, but how are you going to support the actual clinical team through it? And then there are those cases where something might have gone properly awry and, a mistake might have happened, for example, and it’s then there’s sort of formal procedures for that,

but then how do you not only support the team through it but extract the learning and the systems areas that have might have occurred to make sure it doesn’t happen again. So, the structure of the debriefing and the feedback process is really important. And who is involved at what level of case at what time for how long and how all those processes work needs careful thought and planning.

And one of the most powerful parts of your talk, certainly for me, was you had this video of you providing care in the emergency department to a real patient who had given you permission to share it, and we saw the things that went wrong that led to this being a memorable case for you and I think we all just sat there feeling empathy for you and for her and all of the team in that situation.

Can you tell us a little bit about firstly how that set up has arisen. How is it that you have those opportunities in your department and in your practice to video record those, clinical experiences?

So, there’s nothing more powerful than video recording. It’s one thing to think about the case, but to just watch it again in real time is just the most powerful form of feedback I think there is. So, a few of the consultants in Edinburgh thought actually, this is a good thing for us to do. And we had, audio visual equipment installed in our resuscitation rooms. I think there’s kind of several aspects that need considered. I think firstly is a, a cultural one. You need to, as a group accept and want to do this. Video recording is always a sensitive area.

There’s people that will always, not want to do it. They just you know, it’s a very opinion generating area. But we as a group actually felt then this this was a useful thing to do. So that’s the first thing. The second thing is you need the tech. You need cameras and microphones, and they need to be installed and obviously it’s quite expensive So you’re gonna have to have some funding. Whilst that’s relatively straightforward, what we were lucky enough with in Edinburgh is that we had a couple of our actually junior trainees who also happened to be IT boffins and were very good at setting up this system from the back end, because it needs all this footage needs to be stored somewhere It needs to be curated and of course then when I come and say that I want to look at this case someone’s got to then unlock it for me because it’s all obviously locked away very securely. You need to have someone that can dedicate a significant amount of time to do that to make it work. And then I think There’s the sort of I guess ethical legal, regulatory, considerations that you need to have and I think, my understanding is that if you just want to watch it for pure feedback and audit purposes, you need to obviously inform everyone, including the patients that’s happening, but you can do that as a kind of generic policy.

You just say, this is what happens in our department, or this is what happens on our HEMS service, if you want to object now type thing. So, you don’t need to do that for every single case. And only in cases like yesterday’s where I want to show you the footage in a more public setting clearly everyone in the footage, we would then obtain written consent for that to happen. So, it’s not actually as difficult as people think you just need to have I guess the will to want to do it and I think where we’ve probably not done quite as well is we don’t use it as much as we could having done all that, we should use it more.

So, you set up the, what sounds like a load of effort to get this technology in. What’s the actual practical way you’ve done all that of going from, I’ve got a patient in front of me, I want to do a recording. Take us step by step because I think people listening would love to know what it takes to get to the stage where you’re using that for education and reflection.

So, actually in our system it just rolls 24 7. The easiest way is you don’t have to push a button or even think about recording; it just rolls. So, all of the, all of our resus bays, the cameras and the audio just rolls 24 seven. I couldn’t tell you how long the kind of loop is. it’s just like CCTV essentially.

Once it gets to probably about a week’s worth, it starts, booting out all of the old data, and then if you have a case that you think, no, I want to watch that you have to be proactive enough to go to the data controller, get access, watch it, and then that case can then be a ring fenced and safeguarded for a period of time

if you want to watch it again. And then after that you would need patient consent to keep it for any longer.

 And you mentioned that some people can feel really uncomfortable about being videoed. Have you had any particular clinicians in training who’ve been worried that this is going to be used as a means of pointing out their bad behaviour or poor care and therefore have really wanted to not be part of it?

We certainly have had the former. Your initial reaction to video is. it’s going to beat me around the head with a big stick. I’m going to get in big trouble. if I do something wrong, it can be used against me. You have to be very careful to guard against that effect.

You have to guard against the big brother effect. Similarly, we fly with video badge cameras on my HEMS service. And there are clinicians that do have that opinion, and they’re very reluctant to use it. I think in general, once you’ve established it the proof is in the pudding.

Once you just don’t ever use it for that purpose, the trust is then established that it’s not going to be like that. In HEMS. the footage just automatically deletes after, a period of time, and you can make that quite short, you could make that 48 hour. And unless, there’s something absolutely catastrophic, not actually in terms of medical error, it would have to be bordering on, criminality that would be triggering all sorts of other mechanisms anyway, if that were to happen. It can’t be used for anything other than debriefing education and learning.

So, you’ve got the recording, people have agreed to it. We talked a bit in St. Emlyn’s before about the structure of a debrief, which I think is a highly skilled thing and shouldn’t be done by people willy nilly on the back of a, I read something about it, text training. You take the video in perhaps in an education session with clinicians. How do you guide them through that education session, when they’re watching so that it’s not just about picking up the faults or laughing at the person who fell over the drip stand or making it educationally valuable?

What’s the next step?

So, the first step, it’s all about trust. So, when I first saw that video of the case yesterday, I was really scared. I had no idea what it was going to be like. I know it was a very challenging case, and I knew that it had all gone horribly wrong. But I wanted to watch the video.

But I wanted to watch it with someone else that was going to be supportive. And that person, you have to trust them. You have to trust that they are going to support you through watching what is clearly going to be a traumatic event. So, you’ve got to have a bit of a process in place. So, that person probably should watch it on, watch the video themselves first, so that they know what is coming up.

They need to prepare it in such a way. It’s like anything with the debrief. You start with the positives, actually, when I looked, when I watched the video, the first thing I, what struck me was I was still saying please and thank you in the middle of this, pretty full-on event. I was like, oh, that’s good. I was still polite. That’s nice. Because I was worried that I would have come across as, a bit of a kind of panicked, maxed out, twat, if I’m honest, and that was just a big relief. So, you’ve got to have someone that is, wise enough, supportive enough, and positive enough to guide that team through the process.

And they need to be prepared, and they need to have seen it in advance for these more, more difficult ones. And then I think it’s important just to allow the team time on their own, actually. Sometimes when I’m doing this with my HEMS crews, I’ll have a quick look at the video and I think there’s nothing particularly awful in here,

 and I’d say to the team, just going to let you watch it. Just the team that were there, the doctor, the paramedic. They need to be in a secure environment. So, they need to be in a room were, they’re not going to get disturbed. No one’s going to be coming in saying can have a peak too type thing.

And just letting them watch it have their own reflections and then undertake a more traditional debrief. Perhaps then zooming in on certain clips of the video certain, snapshots where significant events or important pieces of information can happen. What is truly amazing, is when you say to a crew what do you think the handover was from the paramedic, for example?

And they tell you and then you watch the 20, 30 seconds of the handover and there’s two or three key bits of information that were just completely missed. And similar to my video yesterday, there’s elements on the video, there are people in the room that you see on the video, I have no recollection they’re even there and it’s like they’re gorilla wandering in.

 Lots to think about and take away, but all very achievable and I think it takes debriefing to a whole new level.

So, you talked a little bit about the cost of setting this up, but then we’ve seen the benefits ourselves in watching you actively reflect on that case in front of us yesterday.

I just wondered if you could tell us a little bit about your experiences of getting to a point in your career, where you are comfortable being this vulnerable in front of your peers and in front of your juniors, because I think it does take some time.

It definitely takes time, and I’d probably say I’m not comfortable. Probably more comfortable now than I was.

I was quite struck earlier in the day when Jas Soar was talking to us about the National Anaesthesia Audit, and he made a comment that the more senior we get, the more susceptible we might be to these sort of sentinel cases, and people, ultimately leaving medicine because of them.

And I have to say, I empathize with that view. I used to think as a sort of junior prehospital doctor that as I grew older, I would develop Kevlar skin and I’d seen everything, and it was impervious to it all. And I definitely think that’s not the case and I’m more sensitive to it. I think for me, it’s what I wanted to get out yesterday was just sharing that kind of experience, because I’m sure lots of people were sitting in the room going, that happened to me or that could happen to me or I’ve had a similar experience or if you do emergency medicine or pre hospital care It’s just a matter of time until something goes badly wrong.

You just can’t go through your whole career without having a really difficult case. It’s just not gonna happen. So, for me yesterday, I was very comfortable wanting to share the message that we should be prepared for them. We shouldn’t pretend they don’t exist. We shouldn’t pretend that we’re all superhuman and can brush them off without even thinking about it.

I think there is a lot more scrutiny on what we do, particularly as prehospital clinicians now than there was, a decade ago, for example. And really importantly, how we support others through it, because I remember at the time being very grateful to senior clinicians who supported me through various difficult cases.

And I think that the supporter role is vitally important, and we need to be prepared to step into that supporter role, with our professional colleagues.

I think it’s fascinating listening to you, because a lot resonates with me that the more senior I get, the more anxious I get about making a mistake and I’ve seen it in colleagues as well, particularly who are edging towards retirement where they don’t want that one defining case before they finish their career.

Chatting to another colleague who practices in Scotland, he’d done a lot of GMC work and looked at a lot of complaints and, other issues that had gone in front of the regulatory body and became more and more worried about that. And actually, more knowledge isn’t necessarily a better thing. It can be a really worrying thing.

 I suppose for less experienced colleagues who are listening, don’t forget that your senior colleagues do have these worries. We might put on a face, and we need to remember that we need to support each other. And I think that’s part of what you’re saying is that nobody is impervious to any of this.

And it can be you on any given day, regardless of how often you’ve been doing it or how long you’ve been doing it.

Absolutely, and it doesn’t always involve a case where something’s gone wrong, you’ve made a mistake. You might actually do a really good job, and the patient has a poor outcome. I do a reasonable amount of expert witness work and actually, it’s fascinating to see again the change over the last 10 years, that the scrutiny prehospital care is coming under is really changing and the expectations are rising. it’s no longer the case that, oh, HEMS went, they must have done a good job. And unfortunately, the outcome was bad. I’ve had the incidents before where, a lawyer has said, show me the line on the SOP that governs the dose of ketamine you give to the patient.

That’s the level of detail. And certainly, I’ve seen some cases, quite recently where, colleagues have been involved in very challenging cases and it’s just luck as to whether you were there, the clinician on the day. Being aware of it and supporting each other is absolutely vital.

I think one of the other things that you drew out as well that might lead us to be a bit more prone to learning from these cases as we become advanced in years, is that we also have more life experience and something you really emphasized nicely was how important the patients are at the centre of these stories.

 Having lived a bit more and having formed more human connections, I think we also start to see those threads a bit more, tangibly than when we were perhaps less experienced. And that allows these stories to get to us in a slightly different way.

Yeah, absolutely. And I think the more senior you get, I think generally you just get more comfortable expressing, your emotion, your views, your reflections, in a way that you probably don’t so much as when you’re a trainee, when you, like you say, Natalie, just don’t have the same life experience.

HEMS services do seem to have a little bit of a reputation of being the macho service who stride in, often people picture us wearing Oakleys, into a scene and we stride in, do stuff, and you’re highlighting that there’s a vulnerability there, but there is perhaps still a macho culture, dare I say, around pre hospital emergency medicine.

Is there a way that we can use these lessons for those services that perhaps aren’t as well developed as KSS and mature in their outlook? What would you say to those services where this reflection just simply isn’t happening?

That’s an excellent question, Iain. And I think the culture around prehospital emergency medicine is certainly changing, with the PHEM program, for example. All of the services in the UK are maturing very quickly, and I think all of

the HEMS services that I know in the UK, do a really good job of, of case review and all the elements we’ve talked about. I think one of my reflections would be, HEMS services go to a tiny proportion of the pre-hospital medicine that is done every day in the UK. We see a very tiny sliver of the most unwell and injured patients, and the vast majority is done by our ambulance colleagues in all of the services across the UK. And that’s where I think that probably the biggest opportunity is. And it’s a very difficult one because, of course, all of this takes time. Case review takes time. And we have the luxury on HEMS of going to one, two, three cases a day, but having lots of time in between, and actually having ring fenced, literally, full days to do case review, in a very structured way.

And I think about, my friends and colleagues in the ambulance service, especially now with the NHS under so much pressure, go from job to job, spend a lot of time, waiting in queues at hospitals, for example. And when do they get the opportunity to do their case review?

How are those systems maturing to support those prehospital clinicians, who we arguably need it, even more than the HEMS crews do. And I don’t have a good answer for that, but I think it’s really important that we remember our ambulance colleagues and actively seek out ways to support them.

So, at KSS, for example, we will actively invite crews to our governance days. We’ll facilitate them doing it, on TEAMs so they can just dial in for the one case, from wherever they may be without having to travel. These kinds of novel ways of. of supporting, case review.

I think COVID, the one good thing about COVID, of course, is everyone can now use TEAMs, and it’s more accepted to, to do debriefs over TEAMs, which, we never would have done before COVID. So, there are technological means that, are helping us address some of these challenges.

I think you’re entirely right. The time is the key, isn’t it? And it’s investing in people. And there’s that long term investment in a short-term society, which is, if I give you this time now to think about what you’re doing, reflect and share your experience, you’ll stay with us longer. And that’s a constant message we hear from lots of senior people, but it’s about getting the organizations to listen.

Richard, thank you so much for your time. I know that you’re busy and heading straight back up to Edinburgh very soon, and it’s very good of you to join us. And lots to think about, not just the practicalities of recording, both in the resus room and the prehospital environment, but then how we use that for education reflection.

It’s been great talking to you. Thank you.

Thank you both very much.