First there was the inquest; now we have the HSE report into the death of Savita Halappanavar at University Hospital Galway last October. Each forum has its strengths and weaknesses, but with careful reading additional aspects of the tragic case emerge.
I have believed from early on that the case was more about the basics of clinical care than about the availability or otherwise of abortion.
Had four-hourly measurements of pulse, blood pressure, temperature and respiratory rate been carried out in accordance with guidelines to manage a pregnant woman whose waters have broken, the clinical team would have reacted more promptly.
If, in turn, these basic measurements had been fed into a modified early-warning score system such as I-Mews, then a stepped management process would automatically be triggered. When a certain score is reached, the midwife is obliged to contact a junior doctor; in turn a higher score means the specialist registrar must be asked to see the patient; and so on until the consultant is called and, if necessary, the patient is transferred to a high-
dependency environment.
Poor communication
But the aspect of Halappanavar's care that increasingly disturbs me is the poor communication that was evident – both between doctors and nurses and among doctors.
It brings into focus the issue of professionalism and why it appears to be relatively lacking in modern healthcare.
The HSE report uses the example of a junior doctor recalling giving all of Halappanavar’s vital signs in a phone call with a registrar. However, the registrar did not recall receiving details of the patient’s pulse rate or blood pressure at this critical juncture.
The investigation team found that, had a formal communication system been in place, the communication of vital information in this and other instances would have been more complete and in all likelihood expedited the patient’s management.
It must be acknowledged that the HSE's acute medicine programme, under Dr Garry Courtney, has been working hard, even before Halappanavar's death, to introduce a National Early-Warning Score (News) system. The key communication tool it uses is called Isbar.
The I in Isbar stands for identification – who you are; S represents situation – why you are calling; B is for background – what the relevant background is; A stands for assessment – what you think the problem is; and R represents recommendation – what you would like the person you are speaking to to do.
If it helps to improve communication in wards and operating theatres, I’m all for it. But I’m also to some extent saddened by the need for it.
Which brings me back to the state of professionalism among doctors and nurses. Professional attributes have changed. Physician autonomy has been limited and doctors are now expected to practice in teams of health professionals. But altruism remains a fundamental expectation of society: doctors and nurses are expected to place patients’ interests above their own.
Learning professionalism
Professionalism is formally taught in most medical schools (disclosure of interest: I contribute to such teaching programmes). In the past, generations of doctors learned professionalism as part of a master and apprentice model of learning, where the attributes of good professional practice were imbued in the tyro.
It’s hard to explain but now that we are formally training medical students and young doctors how to be professional, why at the coalface of patient care does the influence of professionalism appear to be diminishing? Are we bad teachers? Or do we need a fundamental change in the education of health professionals to include specific instruction in teamwork?
Or, whisper it, but was the old hierarchical system, tinged with a soupçon of fear of being exposed by your seniors in front of your peers, safer for patients? Put another way, do a younger generation of hospital consultants need to crack the whip to a greater extent so that junior staff are in no doubt as to what is and what isn’t acceptable professional practice?
mhouston@irishtimes.com
muirishouston.com