The Best Start in Life by Laura Gibson

  • Getting It Right For Every Child
  • Giving children the best start in life
  • Making Scotland the best place to grow up
  • Improving the life chances of children, young people and families at risk
  • Reducing health inequalities

These high level national aspirations underpin much of the work that we, as healthcare professionals, are involved in delivering on a day to day basis. And achieving them does not start with children, the early years, or even pregnancy. It begins before conception. And I thoroughly believe that we are missing an opportunity. An opportunity which is inexpensive, evidence based and highly effective. That opportunity is better promotion of preconception health and care.

What is preconception health?

image1-2There is a clear link between a mother’s health before pregnancy and her baby’s health. We know that healthy women and men are more likely to have healthy babies who grow into healthy children 1. Therefore, thinking about, and improving, your health and wellbeing before conception increases your chances of a safe pregnancy, a thriving baby and a rewarding parenthood. Preconception is the safest and most effective time to prevent harm, promote health and reduce inequalities (pregnancy and birth outcomes are not as good for people living in the highest deprivation).

 
Currently, most people only consider two stages: avoiding pregnancy or being pregnant. With around 40% of all pregnancies being unplanned, the middle stage of preparing for the best possible pregnancy continues to be overlooked; in terms of policy, professional practice and individual thinking across Scotland. Where delaying pregnancy is the norm in Scotland (the average age of giving birth is 29.5 years, and 28 years for first time mothers), taking action to avoid pregnancy is not the same as preparing well for pregnancy.
image2Preconception health is about preparing for pregnancy, whether for your first pregnancy or your next pregnancy. What you do, or don’t do, before the pregnancy test says ‘yes you’re pregnant’ really matters. The choices you make and the actions you take before conception can make a big difference to you and your baby. That is true even if you haven’t given much thought to when you’d like to become a parent.

 
However, preconception health is not just for women, it is important for men too. There are steps that future fathers could take before creating a baby, for the sake of his own health and for that of his partner and their baby.

 
The infographic below, developed by Dr Jonathan Sher, an independent consultant and respected author of numerous published reports and blogs 2, identifies the steps women (and men, where relevant) should take to improve their preconception health:

image3-copy

Why promote preconception health?

Many things that may put your baby’s health at risk, such as smoking, drinking alcohol, taking drugs (prescribed or not), being overweight, being very stressed and some medical conditions, can all make an impact before you even know you are pregnant. That is why planning and preparing for pregnancy are so important.

 
However, not all the negative possibilities of pregnancy are inevitable. Many miscarriages, stillbirths, too early or too small babies, birth defects and other problems may be prevented and the odds of a good outcome can be improved. Good outcomes should not be left to luck alone. Doing what you can to become as healthy and ready as possible, and getting help if required, is hugely beneficial for yourself, your partner and your baby.

 
Traditionally, health promotion for pregnancy begins in the antenatal period, most often from first contact with Maternity Services at around 8 to 12 weeks of pregnancy. Many women are not aware that they are pregnant during the early weeks and months, and unfortunately it is not uncommon for women and men to continue negative health behaviours such as smoking and drinking alcohol through this important stage of early foetal development. Getting ready for pregnancy is as important as getting medical attention once you know you are pregnant.

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The concept that “every contact is a health improvement opportunity” demonstrates that all health and social care service providers who have contact with women and men of reproductive age can make a significant impact on optimising the preconception health of their service users. By utilising every opportunity to promote preconception health and to support women and men to make healthy lifestyle choices, the health and wellbeing of women and men who plan a pregnancy, as well as those who find themselves with an unintended pregnancy, can be maximised.

 
How can we incorporate preconception health into our work?

A new Preconception Health Toolkit that has been designed, tested and refined using Early Years Improvement Methodology will soon be available to support staff across all agencies to raise the issue of preconception health with their service users. The Toolkit includes information on risk indicators for adverse pregnancy outcome, health enhancing behaviours, tips for raising the issue and other suggestions for raising awareness.

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The Preconception Health Toolkit will be launched next Friday 27th January at an event at the Garroch Training Centre near Dumfries, 10am-11.30am. Dr Jonathan Sher, independent consultant, will deliver an interactive key note address. There are still places available, please contact me at lauragibson1@nhs.net if you’d like to participate.
Following the formal launch, the Toolkit, which has been developed specifically for non-specialist staff, will be available electronically to all staff and volunteers in the statutory and third sectors. Please contact me to request a copy or download it from http://www.sexualhealthdg.co.uk.

Laura Gibson, Health and Wellbeing Specialist, DG Health and Wellbeing, Directorate of Public Health

References

Royal College of Obstetricians and Gynaecology (2008) Standards for Maternity Care Royal College of Obstetricians and Gynaecologists; London

J Sher (2016) Prepared for Pregnancy? NHS Greater Glasgow and Clyde (Public Health)

3 Woods, K (2008) CEL 14 Health Promoting Health Service: Action in Acute Care Settings The Scottish Government: Edinburgh

Life after Life by Thalakunte Muniraju

Why should the good things in us stop after death when there is great opportunity for life to continue after life? It is impossible to describe in words the emotional and physical trauma individuals with chronic organ failure experience. I am sure most of you have seen or come across someone whose life has been transformed for the better after organ transplantation.

Kidney failure needing dialysis reduces quality of life and survival significantly. A patient in his/her 30s with kidney failure needing dialysis has a similar chance of having heart disease compared to someone in their 80s without kidney failure. Dialysis replaces some of the functions of kidneys, but not all. Receiving dialysis is almost like having a part-time job; sometimes it can be more than a full-time job if we take into account all the dialysis-associated complications and procedures. To make matters worse, dialysis patients must adhere to lots of dietary and fluid restrictions. A friend of mine once told me that he only started appreciating the taste of water after starting dialysis.

Kidney transplantation is the only treatment which can cure and improve the quality of life and survival in these patients. Yes, kidney transplantation is not without risks and patients have to take lifelong medications to suppress their immune system. But the overall benefits are far superior to being on dialysis. Survival of transplant patients and kidneys has improved significantly – half of the kidneys transplanted from living and deceased donors are still working at 15- and 10-years respectively. One of the immensely satisfying things to see for us as clinicians is to see patients leading a normal life following transplantation.

With the exception of living donation, organ donation is only possible following a sudden, unexpected and most often premature death. We should never lose sight of the families who go through this and should do everything to support them. One of the ways to salvage something positive out of these dreadful events is through organ donation.

Three patients die everyday in the UK waiting for an organ. Over the last 10-years, the number of transplants being performed has increased substantially. Still, a huge gap exists between the numbers of patients active on the list and the number of patients being transplanted (see graphs below). The current UK strategy for organ donation and transplantation, Taking Organ Transplantation to 2020, emphasises the pressing need to reduce family refusal rates. It is disappointing that there has been no improvement in the overall consent (or authorisation) rate in 2014-15. NHS Blood and Transplant continue to devote considerable attention to improving the support that it is giving to families when the possibility of donation is raised.

Muni 1Muni 2On 1st December 2015, Wales became the first UK country to introduce a “soft opt-out” system for organ donation. It will be interesting to see what impact this will have on the number of transplants in Wales in specific and subsequently, the UK as a whole. Earlier this year Scottish government said it would consider bringing forward new legislation on an “opt-out” system for organ donation.

Hopefully one day in the near future we will see an “opt-out” system in whole of UK, for the benefit of our patients with organ failure.

Muni 3Muni 4

 

 

 

 

 

 

Registering online takes less than two minutes. After registration make sure that your family and friends know about your wishes. This is the only way to continuously increase the transplant activity, and give someone gift of life. Please consider giving life after life…

https://www.organdonation.nhs.uk/register-to-donate/

http://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2014_15.pdfb

http://www.bts.org.uk

Dr Thalakunte Muniraju is a Consultant Nephrologist at NHS Dumfries and Galloway

 

 

Three generations of surgeons, born in the wilderness by @fanusdreyer

Olifantshoek

Olifantshoek is a small town in the south-east corner of the Kalahari desert, in a “poort” where a seasonal river flows through. Seasons here are measured in years or decades, not months, but there is enough water so that the town dam only occasionally runs dry. In the Northern Cape and southern Namibia children regularly get to school age without ever having seen rain. In the 1920’s my grandfather was the Dutch Reformed minister in Olifantshoek.

One day in 1922 granddad travelled to Bloemfontein for the church synod. He was a bit of a technophile so he was one of the first in the region to own a car, although he did his parish visits on horseback due to the roughness of the terrain. After the synod he gave a lift home to a Rev Brink from Danielskuil, another small town on the edge of the Kalahari. They got to Danielskuil late afternoon, granddad was treated to an evening meal (the Brinks have always been superb cooks) and offered a bed for the night. He declined as his wife was nearing the end of her pregnancy and he wanted to get home that night. Rev Brink knew of a shortcut along farm roads but this had lots of gates to be opened and closed. He then offered that his six year old son could accompany Rev Dreyer, show him the shortcut and open and close the gates for him. Granddad gladly accepted and they got home by 1 am. And so it was that my future father-in-law helped my grandfather get home to my grandmother, who was expecting my father’s birth any day.

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Dad grew up during severe drought and the Runderpest in the 1920’s Great Depression; the only animals still alive in Olifantshoek were donkeys. It was so dry that grandma had to send a bottle round the streets; everyone who had a little bit of donkey milk to spare would put it in the bottle so she would have just enough to feed a future ground-breaking surgeon.

In the 1950s Dad helped to develop potassium cardioplegia for open-heart surgery while working with Sir Ian Aird, got married to Mum in Edinburgh with Dr Davidson (of the internal medicine textbook) as best man, then went back to Cape Town where in 1958 he did the first technical successful heart transplant in the laboratory by swapping two dogs’ hearts; they lived three days until rejection set in. He was invited to join Dr Willem Kolff (who had built the first dialysis machine) in Cleveland, Ohio, to work on the first artificial heart programme. On his return to Cape Town he went back to general surgery because he thought heart surgery was too boring.

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First patient, and a decision

It was 1975, somewhere in Southern Angola. I had decided to go for national service because I was not sure what to study. We were pions in a West-East imperialist war for future control of Angola’s riches. We drove into the ambush at dusk and James took a bullet through the ankle. Mark, James and I were lying under the same truck we were in 4 hours earlier. Angolan rain was no joke. We got his boot off; his ankle was getting bigger by the minute, and blue. We had no idea what to do, so gave him 4 Codis tablets and wrapped the ankle so we wouldn’t see the dark blood seeping through, but it looked like toilet paper on a stick. If only we had a proper medic.

The codeine-aspirin combination did not help much for James’ pain, but it made him talk. There was nothing more we could do, but lie next to him to keep him warm. And whisper. The sergeant was on the radio, trying to get an air evac. We knew the chopper pilots would not fly tonight, maybe drunk again. They’re sending an ambulance which will take hours, the road is mined.

At first light the ambulance arrives. James’ leg looks like it will fall off any moment. “Thanks boys” he says, “you’re good to sleep with”. “See you” we said.

We never saw him again but heard that the army doctors saved his leg. “Good outcome” they said. A stiff ankle gets you an honourable discharge for medical reasons. Not a good outcome for a champion 800m athlete. On an Eastern Cape farm you can ride a horse or pick-up truck; there’s no need to run.

The next week I got a message to Dad: “Please confirm that place in medical school, forget engineering”. It took me another 20 years to understand that often we can do nothing for patients except offer them comfort.

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Malawi boy

It is 1985. Every time I looked at her, she seemed more uncomfortable. Her legs were more swollen every day. Pre-eclampsia is not easy in the tropics but maybe it’s not easy anywhere. It was too late to fly her out to South Africa. After the scare with premature labour at 32 weeks she was not flying anywhere anyway. She was now 38 weeks, “so we made it” we thought. Our baby was going to arrive in a small mission hospital in Nkhoma in the Malawian bush. “Time for an induction”, I said, without thinking much of informed consent. Working amongst so much extreme poverty did not give time for reflection.

With the senior midwife we started her on Pitocin on the Saturday. No contractions followed and the cervix was not yet ready. Should we rupture the membranes or wait? We decided to wait 48 hours.

We tried again Monday morning. By now the blood pressure was borderline high and there was 1+ proteinuria. If the induction fails today she would need a C-section. “Who will do the Caesar”, the midwife asks. “I will” I say, “after all, the others ask me if they have a problem case”. This time she responds well to Pitocin. Within an hour she has good contractions and the membranes rupture spontaneously. I feel for a cord but there is none. Four hours later she is fully dilated. She has a lot of pain. I’m too brusque, so focused on being a doctor that I forget to be a husband and expectant father. She has a boy, 3460g, Apgar score 10/10. I suture the episiotomy; she’s embarrassed. “Don’t worry” I say, “nobody will do this better”.

That night we all slept in the same hospital room, our new son with his mother, our two year old daughter and I on a mattress on the floor. We shared a bathroom with an AIDS patient with resistant malaria, the first HIV positive patient diagnosed in our small hospital.

Today he is 30, has taught in Africa with me, and recently we shared working together in Dumfries. A few weeks before he was born I went to an East Africa surgeons’ meeting and heard Dr Imre Loeffler speak, a Hungarian-Austrian surgeon who gave his whole life to surgery in Africa. He said that a first class surgeon could operate in a hammock slung between two palm trees on a beach and have better outcomes than a second class surgeon working in the most modern theatre. A few months later, when in South Africa to show the new boy to the family, I went to see the prof to get a training post. I started one year later.

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Full circle

Before starting surgical practice in 1992 in Upington, the main town of the Kalahari, I went to see GPs in the region, and that took me to dr Jan Meyer in Olifantshoek. He promised to support me. After our meeting I thought to try and find the old Dutch Reformed manse where Dad had been born 70 years before. Dad’s brother had told me that the building commission drew the house plan in the dust with a stick, and according to that the building started. Now there was a new church and manse, and I opened the gate with the “Pastorie” sign, rang the doorbell and asked the young inhabitants if they knew where the old manse was. Nobody knew. I walked dejectedly to my car and, as I started the engine, an old man walked past; he looked part-Tswana, part-San. I rolled down the window and asked him if he maybe knew where the old NG Kerk Pastorie was. “Oh I know exactly where it is”, he said, “it is the house with a wind pump in the back garden”. I asked him to take me there and he got in, moving very slowly because of rheumatism. It was two blocks down, around the corner in a dusty street, a small little square house, still with a wind pump in the back garden, watering all sorts of vegetables and maize patches. I got out to take a picture. The owner came out and asked what I was doing. When I said my father had been born in the house he showed me round. Afterwards I drove my guide to his house in the old African township and I asked him how he knew the house. “When I was a schoolboy, I used to work there on Saturdays for a Reverend Dreyer”, he said; “He paid my school fees. If it was not for him I would not have been able to read and write”. I stopped the car and we both shed a tear for this generous and humble man whose names I wear with pride.

Jan Meyer kept his promise. The first patient I operated on after setting up practice in Upington was an elderly diabetic from Olifantshoek. His father was the lead elder when my grandfather was appointed minister. Granddad did his catechism and I took out his gallbladder; it was beginning to become gangrenous, typical of a diabetic.

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My father and my son have surgical dispositions, much more than I could ever have. When the boy was working in Dumfries, staff kept telling me how he was becoming more like me. That was only half the truth as I was also learning from him. It is when the son not only emulates the father but the father subconsciously starts to emulate the boy that the relationship becomes complete, like my 93 year old father has become dependent on our conversations as much as I once needed his advice. And so we live and learn, love and one day die, in sync and at peace.

@fanusdreyer

http://www.albacccd.com

Kathleen’s Journey

How many of you have lost a loved one to cancer? How many of you have heard the term “he or she died peacefully”? Anyone who has witnessed a loved one dying in this way will appreciate that there is often nothing peaceful about it. It is heartbreaking, you are in fearful limbo, undergoing constant challenges and the result is painful and exhausting both physically and mentally. This may sound a little dramatic but it is an honest assessment and it was honesty which I felt was lacking in the story I wish to tell you.

At the beginning of 2014 Kathleen, my Mum, had a follow up Colonoscopy having previously had polyps. However on the day the procedure was performed there were complications and the test was abandoned. She was informed she would be recalled but sadly had not yet received this appointment at the beginning of 2015, when she died.

She became unwell during the summer of 2014; fatigue, loss of appetite and change in bowel habit. As her symptoms worsened she isolated herself socially. Her GP prescribed laxatives but they just made things worse and caused abdominal pain. I would say at this point she had no quality of life. She visited her GP and asked for more investigations but was informed that tests such as CT scans were expensive and she did not require one. This shocked us.

In November her abdomen became distended and the pain became worse. We were left with no option other than to take her to the Emergency Department. To my horror Mum was sent home with more laxatives but was so poorly had to return the next day. Once again they wished to discharge her but my dad stuck to his guns and insisted on admission. She had a number of tests and on the following Tuesday a CT of her abdomen. This revealed bowel and ovarian cancer. 

When Dad was asked by the Consultant to be present when he gave Mum the results he knew it was going to be bad. The Consultant informed them that the cancer had spread and that Mum only had weeks to live. There was no treatment to offer. There is no skirting around news like that. It was devastating but we were grateful that it was delivered with humanity, compassion and honesty. You don’t forget these things. As a family were reeling. The grandchildren were heartbroken and we all struggled to come to terms with the news. And then…..

A few days later another doctor came and told us the CT results were ‘inconclusive’. This news was delivered with a flippancy and obvious lack of understanding to how we all felt. We were then told that it would be over a week until we knew what the plan was as we needed to wait for a multidisciplinary meeting. This was almost too much but we clung to the hope now presented to us. Maybe….

Then we were told that there was no curative treatment but there was an option of palliative chemotherapy which MAY shrink the tumours. They offered 6 months of chemo which sounded hopeful and Mum went up to Edinburgh. However after the first course she suffered a perforated bowel, apparently as a result of the chemo, and was admitted to the palliative care unit. She was now asked what she wanted and discussion turned to the funeral!

Why was my Mothers final 6 months such a roller coaster? Why did it take so long to diagnose her? The end result would most likely have been the same but did she have to go through so much pain and confusion? I understand that an administrative error led to Mum not getting her follow up colonoscopy. This is inexcusable but when she became truly ill no-one seemed to listen to her. Listen to her symptoms, listen to her story. Had an individual healthcare professional actually listened to Mum or Dad and taken them seriously then I have no doubt she would have at least had her scan and diagnosis earlier.

And then all the confusion about “was it cancer or was it not?” It clearly was and the first Consultant we saw was clear about this and, not only did he honestly tell us the news and prognosis, he was right: she only had a few weeks left. A few weeks that could have been much kinder had she not been given false hope and a worthless (and uncomfortable) trip to Edinburgh. It was only when she got to the palliative care unit that they asked….What matters to You?

That is all it required….someone to listen and honesty.

Mum died in the palliative care unit well cared for and in dignity. The staff were honest and kind. They listened to her needs and provided them. We are very grateful to them and their professionalism.

This week’s blogger wishes to remain anonymous

Communication by @kendonaldson

“My father was in hospital for 2 weeks and not once did I get to speak to a doctor”

“All it would have taken was a phone call, I kept asking day after day, but no-one bothered”

“We were watching Mum get sicker day by day and we knew she was dying but we couldn’t get anyone to talk to us about it. They kept changing drugs and trying new things but nothing was working. We knew she was going to die”

These are just a few quotes from recent complaints that I have read and demonstrate a very common theme – we are not very good at communication. There are many aspects to our failing in communication; with the patient themselves, between specialist teams or between primary and secondary care but it’s the communication with families and loved ones I wish to focus on in this blog.

To illustrate my point here is a short story. A friend of mine texted me about a year ago. I was aware that her mother had been in hospital but did not know the details. This was the text she sent me…

KD 1

I decided to phone the hospital myself and managed to get through to the Consultant looking after her mother. He started to tell me the details but I stopped him and asked him to phone my friend – she was the one who needed to know. His response was “I’m in an MDT meeting and too busy. Tell her to call my secretary and I will meet up with her in a few days.” I was a tad persistent, gave him her mobile number and said “Please phone her today. 5 minutes, thats all it takes.” He was unhappy but said he would try. A little later I received the following text…

KD 2

(Note my text was ‘Not Delivered’. Great communication!!)

And the next day….

KD 3

So, a 5 minute conversation with the consultant completely changed that individuals ability to function at work and at home. 2 weeks of agitation, worry and poor sleep gone….in 5 minutes. So why hadn’t that conversation taken place much earlier? Why did the consultant feel the need for a ‘face to face’ meeting? I would agree these are always much more satisfactory for all concerned but they are sometimes difficult to organise and end up delaying the communication for days. All it took was a phone call.

It got me thinking about my own practice. Do I speak to relatives enough? Am I proactive in phoning families to update them on their loved ones progress? The answer to this was no, so I had to do something about it.

It may seem an overly simplistic approach but what we have done is introduce a ‘Ward Sticker’ (see below) which is effectively a checklist which we put in our patients case sheets at least once a week (sometimes less, sometimes more). Now this list covers many things of which ‘Family discussion’ is only one but it is a way of ensuring that, on a ward round, someone has asked the question “Has anyone spoken to the family?” If the answer is no then we can organise that it happens but what I often do is just pick up the phone and call them. Unless it’s really bad news I don’t see any problem with a phone chat and, often, the information I get from them is extremely useful and changes management plans.

KD 4

Do I get it right all the time? Again, no. It was only a couple of weeks ago that my colleague reviewed a patient in our Medical High Dependency Unit who I had seen several times over the preceding few days. She was young and very sick and, he informed me very politely, no one had spoken to her daughter since admission. I was mortified but then we don’t use the sticker on MHDU. Am I becoming reliant upon it? Must do better!

There is no doubt our patients are getting older, more complex and are increasingly muddled, especially on admission. Making a clear and definite diagnosis takes longer and often feels less than satisfactory – ‘Probable UTI’ or ‘Probable Stroke’ – and its in these scenarios that early family input can make a massive difference. You can feel like you are working in the dark but when you pick up the phone and speak to someone who knows the patient well, and really cares for them, then it can become clearer and, I think more importantly, you can allay that loved ones fears about what you are thinking of doing in the way of tests and treatments.

So if there was one thing I could ask it would be this – think about the family and loved ones early on in admission (preferably the first day) and use your phone a little more. A quick phone call can make a big difference and will often calm their anxieties, make your life easier and, perhaps, reduce the number of complaints coming through the system.

KD 5

Ken Donaldson is a Consultant Nephrologist and Associate Medical Director at NHS Dumfries and Galloway