Abigail Whiteman
Abigail is a consultant in anaesthesia at University College Hospital, London and an honorary associate professor at UCL. Her main specialist interests are perioperative medicine and medical education
Activity
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Abigail Whiteman replied to John Orton
Fantastic summary @JohnOrton
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Thank you Daiva: I agree a protocol often wouldn't fit this patient group. But what about a pathway ensuring that there was a more holistic view of these patients: assessing for multimorbidity, frailty and POCD and providing MDT care? We will look at just this in a few steps time.
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There is no clear or single intervention proven to modify the syndrome of frailty or to impact on postoperative outcomes in frail individuals. However, improving outcome in high-risk patients is likely to depend on earlier recognition of the high-risk frail individual, followed by risk stratification and optimisation, with the aim of modifying the degree of...
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Sounds like a review of process is definitely needed! I agree that POM is all about care co-ordination and attention to detail. Can make sure a difference to a patient's outcome.
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Abigail Whiteman replied to William Thompson
I agree @WilliamThompson. Close liaison with the GP or family doctor is so important so that chronic conditions identified at PAC can continue to be monitored and optimised. What makes you fitter for surgery makes you fitter overall!
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Thank you @EwanRoss. I agree it is not widely known about or discussed with patients pre-operatively. Raising awareness amongst the whole MDT is key as it's prevention and management requires an MDT approach.
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Abigail Whiteman made a comment
So pleased to see so many learners staying with us through to the last week. This week is my favourite: the unique perioperative problems of the elderly, POCD, frailty and a brief look at how COVID has changed perioperative care. Do let us know your thoughts on these.
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Frailty is indeed an independent risk factor for a poorer outcome. We will be covering this in much more detail next week- stay with us for that.
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Thank you Elizabeth. The concept that the operation is only the start of the journey is one we don't yet teach well pre-operatively. I agree that psychological support in recovery would be immensely valuable.
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Abigail Whiteman replied to Guy Titley
But it's one that's easy to remember and patients can engage with- teaching them to dream!
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Abigail Whiteman made a comment
Thank you for all your positive comments about the app. Finding easy ways of data collection is so important if we are to prove benefit and implement positive change.
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Abigail Whiteman replied to Charlotte C
@CharlotteC - that's an interesting outcome. Is that still the case? Is the ER programme still running? Has benefit been proven?
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Abigail Whiteman made a comment
The common themes in this thread and the poll results show that most of you are very positive about protocols:
-they aid juniors in making decision
-they ensure a basic standard of care for all patients
-they assist in quality assurance and education for the whole MDT.
I agree with all these points. Reducing variation improves care. However, I also...
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I agree @GrahamHastie- any systems change needs strong leadership to implement and sustain.
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The PREVENTT trial did prove that IV iron was very safe: we will learn more about that in the next few steps. The risk of anaphylaxis/severe hypersensitivity reaction is thought to be less than 1 in 250 000.
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I agree Guy. I think the benefit (both patient and cost) probably needs to proven incontrovertibly before it could happen on a national level. In the meantime we need to give teams the resources to do this. CPOC have also recently updated their guidance and is a helpful...
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Delighted to have orthopods on the course! Hopefully you will find the learning in week 3 about protocolising the management of patients with hip fractures of particular interest.
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Abigail Whiteman replied to Charlotte C
I agree: it is something we as clinicians need to learn to do well. We often haven't been taught the skills to properly involve patients in their own decisions. You might find the shared decision aids in the next step useful!
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Omar- I completely agree about health literacy and empowering those with lower health literacy. Alongside that, we as clinicians need to learn to tailor the information we give to make it appropriate for each individual patient and their families.
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Abigail Whiteman replied to Abigail Whiteman
Hello Helen,
I am sure if you got in touch with the POPS team administrator she would pass on your message to the appropriate person. There are contact details on their website: https://www.guysandstthomas.nhs.uk/our-services/ageing-and-health/specialties/pops/overview.aspx
Good luck with it all- a fantastic thing to undertake! -
Thank you very much for sharing how the three delays are very real.
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I completely agree Christopher: we go onto discuss the role of risk assessment tools next week and this is a very important function of them.
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Abigail Whiteman replied to Siaelda Green
Thank you @SiaeldaGreen. I completely agree that a holisic patient view and an MDT approach is the way forward.
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@Christopherparnell I agree- I think it is a really important practice. We will cover this more next week.
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Agree, a much more costly reactive approach.
A proactive patient centred approach with elective admission to a PACU, and subsequently avoiding complications, would improve outcomes and be considerably more cost effective! -
Great to see more surgeons on the course: please do spread the word to your collagues! @AmiraShamsiddinova I completely agree that a joint model of care would be the best way forward. The POPs model (https://www.futurelearn.com/courses/perioperative-medicine/9/steps/1072925) is an example of where this works extremely well.
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Thank you @ChristianaTamakloe. Really interesting to hear about the surgical pathway in Ghana. Do you feel this set up works well for complex patients?
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Abigail Whiteman made a comment
I have been reading through these comments with great interest: already on only the second day of the course Mary's case has generated a lot of discussion and debate.
I agree with you all: there were many ways in which Mary's perioperative care could have and should have been better.
As we will explore in the next couple of steps, avoidable...
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This is a lovely definition Jessica.
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Abigail Whiteman made a comment
Really delighted to see so much discussion already. I know this is self selecting group but it is great that so many participants are already so positive about the benefits of POM for patients. We hope to persuade you over the next few weeks that it is not only beneficial for patients but also the most cost effective way to provide health care.
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Abigail Whiteman made a comment
Thank you all for your very kind comments: we are delighted that you have found the course useful and hope it will inspire some change in clinical practice. Please do spread the word about the course as, COVID allowing, we hope to run it again in early 2021.
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Thank you @FionaHansell - a really great post.
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@TanyaJones I completely agree. In my trust, anaesthetist presence in the MDT is gradually increasing. This must be of benefit to the patient.
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That's great to hear @VictoriaWhite. If overall, it reduces post operative morbidity, it would be a worthy investment!
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However, the poll results are not as skewed as I would have expected!
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Abigail Whiteman replied to C Soo
@CSoo Yes, there were fewer readmissions in the IV iron group. BUT this was a secondary outcome and the study wasn't powered for this. It's a positive signal but has to be treated with caution.
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Thank you- well spotted! I'll change it now.
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Thank you @ThomasGeorgiou. That may change if your hospital chases the best practice tariff. At UCH we attend for all laparotomies with a predicted mortality >5% and this is rigidly adhered to.
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@EmmaPickavance I completely agree.
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Abigail Whiteman replied to Eva Watson
Thank you @EvaWatson. Sounds like you have a very good set up at your hospital.
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I certainly hope that is not the answer! Maybe we need to tailor our pre-op management a bit more: large doses of IV iron, epo, folate...
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Indeed, intra or post op infusions would mean a significabnt reduction in infrastructure and cost.
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Abigail Whiteman made a comment
Delighted to see so much discussion about the results of the PREVENTT trial. I think the positive results of the trial (46% reduction in readmission to hospital) do have to be treated with caution: this was a secondary outcome and trial was not powered to detect a difference here. However it is a signal that it might have benefit: more work in this area...
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Thank you! I will take this back to Danny and allow him to answer.
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Thank you @SM. Can I just check what you meant by your first comment? Have we made an error with the editing? Many thanks.
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Thank you @ShambhuAcharya. I think it is so important that this vital step of diagnosing the cause of perioperative anaemia is not missed even if we are able to effectively treat and manage the anaemia pre-operatively.
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@DavidGeorge I completely agree.
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Abigail Whiteman made a comment
The common themes in this thread and the poll results show that most of you are very positive about protocols:
-they aid juniors in making decision
-they ensure a basic standard of care for all patients
-they assist in quality assurance and education for the whole MDT.
I agree with all these points. Reducing variation improves care. However, I also agree... -
Abigail Whiteman made a comment
Thank you all for your comments. It is so very positive that most of you report you will change your practice and adopt a more patient centred approach. I am also delighted that the younger cohort of doctors are reporting that shared decision making is now core to the curriculum in some medical schools: this is a very positive step.
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Thank you @HanMyoAung Why is that? Is it familiarity and what is commonly used in your insitution or do you feel the model is more representative of your patient cohort?
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Abigail Whiteman replied to Fiona Hansell
I agree @FionaHansell . I think sufficient time pre-operatively for decision making is a very good investment. It enables patients to feel confident in the decision they make. With the advent of more video consultations, multiple consultations may not be the burden it once was.
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Thank you for your comment @RajkumarParikh . We cover POCD in much more detail in week four: stay with us for that.
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Abigail Whiteman made a comment
Thank you all for sharing your experiences: both positive and negative. I think it is a really useful exercise as it really help us recognise how vulnerable our patients feel before, during and after surgery.
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Thank you @AndrewMcKendry. We deliberately left the clinical histories shorter so as not to overwhelm with details. These are fictitious patients to try and introduce the whole MDT to risk assessment.
Please feel free to embellish the clinical vignettes with whatever details you need and then give a rough estimate as to what you think their 30 day...
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Abigail Whiteman replied to Andrew McKendry
I expect that was the fault of the novice interviewer (me) rather than Ramai not having very valuable contributions to make. Fortunately she wrote all the accompanying text so you can hear her voice throughout all of that.
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Abigail Whiteman made a comment
Reading through all your comments it is clear that there is consensus that the perioperative pathway should start from the moment a referral is made for surgery and should end after rehabilitation is complete. There is also general agreement that a whole MDT of healthcare professionals should all be involved.
I have found the discussion about our GP...
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Thank you @KatharineGanly, I completely agree with your comments about communication and early shared decision making; we cover this in more detail next week.
I agree it is difficult to know exactly what we could expect our GP colleagues to address in the community.
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Abigail Whiteman made a comment
Thank you all for your very positive comments about the first week. We are really pleased that we have raised awareness about perioperative medicine in paediatrics and perioperative medicine in obstetrics. Do stay with us for the next week where we look at shared decision making, risk assessment and measuring outcomes.
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Abigail Whiteman replied to Thomas Thorp
@ThomasThorp I agree. We cover how to do effective shared decision making next week.
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Really delighted to see so many geriatricians on the course this time!
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Abigail Whiteman made a comment
I am pleased you are all finding thee CPOC resources helpful. I agree that the Fitter Better Sooner resources are very high quality. I also particularly like their new rapid research review summarising the evidence base that perioperative medicine improves care, improves outcomes and reduces healthcare...
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@ThomasGeorgiou only one: its a poll to gauge opinion as we start. We can compare how learners opinion change from the beginning to the end of the week.
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@EmmaPickavance I am sure your input will be incredibly valuable for the complex vascular patients. The lack of time of optimisation is something we all struggle with. In week 4 Prof Mike Grocott makes the case that we should review patients at the same time as the surgical referral to overcome this barrier.
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Although the best practice tariff does provide more or a 'carrot' approach to drive improveement. For those who are not familiar with the details of NELA we cover this in great detail in week three.
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@AndrewMarkRogers I agree. There is a suggestion that there has been maximal improvement possible with good leadership in individual areas but further improvement requires cross specialty collaboration and system redesign: much harder to undertake.
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@SophieB I completely agreee. Stay with us in week 2 where we see a the impact this information had on a man having major surgery. Patient empowerment is so important.
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Thank you @GuillermoRuiz .Good communications between the multidisciplinary team is so important.
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@ThomasThorp I completely agree and we attempt to define this patient group throughout the course.
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Thank you for your comment @HosamMarie .It is interesting that an internal medicine physician is commonly involved in pre-assessment in Egypt. I wonder if that means the patients have their medical conditions more thoroughly optimised before surgery? Some centres in the UK have geriatricians involved pre-operatively and that works very wellin high risk patient...
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Abigail Whiteman made a comment
I have been reading through these comments with great interest: already on only the second day of the course Mary's case has generated a lot of discussion and debate.
I agree with you all: there were many ways in which Mary's perioperative care could have and should have been better.
As we will explore in the next couple of steps, avoidable...
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Abigail Whiteman replied to ALEXANDER ABRAHAM
@ALEXANDERABRAHAM I completely agree with your comment that assessment should have included an assessment of frailty and risk assessment for POCD. We cover this in detail in week 4: stay with us for that.
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Abigail Whiteman replied to SAMUEL LAWRENCE
@SAMUELLAWRENCE I agree: multidisciplinary input leads to better patient care
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Abigail Whiteman made a comment
Reading through your posts I am delighted to see so many of you are already feel so positive about perioperative medicine. This is reflected in the results of the poll where 98% of over 6000 respondents agree that perioperative medicine will improve care for high risk surgical patients. I am excited to see how much we can change practice over the next few weeks.
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Abigail Whiteman replied to Katie Samuel
Hi Ziad, It will give you a broad view of how we should care for high risk surgical patients which is important for an ODP. You may also like to look at our other online course which is currently open which would also be very relevant to your learning: www.futurelearn.com/courses/airway-matters
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Abigail Whiteman made a comment
Great to see so many positive comments about the Airway Spider! It is all the hard work of a team led by Fiona Kelly who you will meet in Step 1.11: Experts Top Tips- stay with us for that! I agree it is a great cognitive aid and easy to apply. The original paper describing the Spider is well worth a read and also open...
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Thanks for the comment @BenMarshall: we look at the Vortex approach in much more detail next week- please join us there to review all the evidence. In the last run of the course it divided opinion and it looks like it will again!
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Abigail Whiteman made a comment
Reading through this thread it is great to hear so many positive comments about gastric ultrasound. Many of you have identified numerous situations where it could really beneficial.
I agree with you all that I hope the technique can become more widespread and then a body of evidence can be built up demonstrating a beneficial effect on patient safety and a...
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Abigail Whiteman replied to bernadette doherty
We look at positioning for the obese and paediatric patient in week 5: do stay with us until then!
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Abigail Whiteman replied to Mila B
Thanks @MilaB we really liked it as well.
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Hi Nicki,
We have a paediatric glidescope in our paediatric theatres but also have some Airtraqs in case of emergency airway management outside of theatres. I think the most most important thing is just for people to be familiar with the kit they have and be given opportunities to use it in the elective (non emergency) setting. -
Abigail Whiteman made a comment
It has been really interesting reading through this thread. Many of you have noted how much more anxious you are dealing with the paediatric population, particularly in the emergency setting. There have been great suggestions as to how to best manage the situation:
- Standardising kit to ensure everyone is familiar with all paediatric equipment
- Aide... -
I agree Andrew: when I am struggling with difficult IV access it is so much easier having an ODP who is skilled at keeping the paediatric airway open and hence keeping the child deeply anaesthetised!
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Hi Brody, I completely agree about insufflation of the stomach. It is so easy to do in younger children, particularly when face mask ventilation is difficult. It can really impact on your ability to ventilate.
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Good question @GarciaGarcíaCovadonga. In the validation paper, the authors explain it by saying 'patients intubated for coma often present increased oropharyngeal secretions, limiting view of the glottis.'
It's an interesting paper to read and you can access it here:
https://www.atsjournals.org/doi/full/10.1164/rccm.201210-1851OC -
What a fantastic idea: that is very forward thinking of your urologist!
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Abigail Whiteman replied to Darren Figgis
Great analogy!
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Abigail Whiteman replied to Nicki H
I completely agree Nicki: shared decision making leads to less 'decisional regret' even if things do go wrong.
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Abigail Whiteman made a comment
Thank you all for your kind comments; great to see so many of you keeping pace with us! We are looking forward to plenty more discussion next week: our fifth and final week.
If you have colleagues who are interested in joining, please tell them that they are still able to and will have seven weeks to complete the course.
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@OSAHENIOSAS Thank you very much for your post. If you are thinking this I can guarantee hundreds more learners are! To clarify
BACT: bougie assisted cricothyroidotomy
eFONA: emergency front of neck airway
pmhx: past medical history
We have tried really hard to explain all acronyms but if you come across any more you don't understand please do flag them! -
Abigail Whiteman replied to Pavel Michalek
Hi Pavel: there are more to come- please do stay with us!
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Abigail Whiteman replied to Michael Munro
Thank you very much for your comment Michael. I am surprised that you seem to be moved around so much; working with a familiar team is so much easier and, I think, safer. Our surgeons and our lead interventional bronchoscopist have been strong and very vocal advocates for this!
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Abigail Whiteman replied to Judith Swan
Great comment Judith: I completely agree!
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Abigail Whiteman made a comment
I am pleased with how positive you all are about the role of the the MDT meeting in planning care for these complex patients. However, many of you have identified the biggest stumbling block: the lack of patient involvement. Team members are concerned they would not be able to speak frankly regarding prognosis and time constraints would mean satisfactory...
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Abigail Whiteman made a comment
Thank you all for your comments: I agree with you all that I think Jen is a courageous and inspirational person.
Recent pedagogical reserach has confirmed that we as healthcare professionals learn so much more from patients themselves. I think Jen's story really drives home how important patient-centred care is.
When you have finished this course,...
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Kate, I completely agree, it hugely reduces the anxiety of this being a time pressurised situation and allows people to perform better.
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In the early days of using THRIVE, Anil Patel always used to use a transcutaneous CO2 monitor. Due to the cardiogenic oscillations, he found that the CO2 did not climb as quickly as he expected. Now, so experienced, in the technique he doesn't use it on every case but does always document the first ETCO2 when ventilation resumes at the end of the case.
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Hi Andrew, I agree: it is absolutely essential that the whole MDT is familiar with the process of jet ventilation before it is used. It is also really important your equipment is properly serviced and checked if it is ever used again.
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Abigail Whiteman made a comment
Thank you all for your comments. I agree with you all that @jignamodha and her team did an amazing job to save this patients life. As you will hear at the end of the next step, the patient was admitted to ITU post-operatively but suffered no long term injury as a result of the fire.
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Abigail Whiteman replied to Darren Figgis
Thanks for your question Darren. Any airway fire should extinguish if any one of the three elements of the fire triangle are removed (we go into this in more detail in the next step). Using sterile water or saline to extinguish the flames is certainly the standard suggested practice. I haven't heard of and can't think of anything else non-toxic that would do...
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I agree Emma: a fibreoptic scope is essential to ensure correct placement of the guidewire and then tracheostomy tube.
