the times | Tuesday August 11 2020 1GT 7
bodyhealth&soul
3
Avoid swimmer’s shoulder
“Swimmer’s shoulder is an
umbrella term for a range
of problems, including
impingement [pain at the front of the
shoulder], rotator cuff problems and
tendonitis,” says Andy Magill, a
physiotherapist and musculoskeletal
expert for Vitality. “It’s often a result
of poor technique and overusing the
arms to pull you through the water,
when swimming actually requires you
to use the torso, core and legs for
optimal efficiency.”
Warming up will help, Todman says.
“Arm windmills and bear hug reps
seem to be most effective for keeping
the shoulder joints mobile. Try small
controlled movements first, slowly
increasing speed and range. Don’t
forget your wrists, flapping backwards
and forwards as you prepare, as they
can also come under strain.”
Peta Beeto avoid pool
injuries
1
Beware breaststroke knee
This stroke’s unnatural kicking
movement puts strain on the
ligaments on the inside of the
joint. “Swimming is generally excellent
for vulnerable joints,” says Sammy
Margo, a physiotherapist, “but the
breaststroke kick is generally a bad
idea if you have arthritic knees or if
you have an existing knee injury.” She
suggests switching to the flutter kick
of front crawl while maintaining
breaststroke arms or putting a float
between your legs to avoid the kick.2
Relax your neck
Holding your head high out
of the water can not only slow
you down, but also puts the
neck under tremendous pressure. “It’s
most common among recreational
breaststrokers and those who do front
crawl, but don’t want to get their hair
wet,” Margo says. “If you do this, make
sure you dip chin to chest at the end
of every length and perform some
neck tension releasing exercises —
chin to chest, chin to ceiling, left ear
to left shoulder, and right ear to right
shoulder — when you finish.”
Strengthening your lats, the large
V-shaped muscles that connect your
arms to your spine, with rowing and
pull-ups is also important, says Matt
Todman, the director of Six Physio.
“Breaststroke requires a combination
of good thoracic spine mobility —
so plenty of foam rolling — but also
decent strength in your lats to enable
good upper-body technique.”distracted driving your taxi or
babysitting your child, yet we allow
doctors and nurses in a distracted state
to be taking care of our bodies and
minds. It’s absurd.”
There can be a tendency for doctors
under time pressure to go for the
obvious diagnosis, she says, and then
to stop looking for further explanation.
Ofri has closely studied the case of
Dr Hadiza Bawa-Garba, a junior
doctor at Leicester Royal Infirmary
who was convicted of gross negligence
manslaughter after the death, from
sepsis, of six-year-old Jack Adcock in- Bawa-Garba was given a
suspended jail sentence for the
mistakes she made in failing to give
Jack the right treatment.
She won an appeal against a ruling
that she should be struck off and she
was given permission to practise
medicine again. Many doctors said
that she had been made a scapegoat
for failures of the system. Bawa-Garba,
who had just returned from maternity
leave, was covering the work of other
doctors, and the hospital’s IT system
was down when the boy died.
The mother of three teenagers,
Ofri has sympathy for Jack’s parents,
but says that the treatment of
Bawa-Garba “seems shocking. I’ve
been that doctor who has been in an
impossibly overstretched situation and
has made mistakes.”
Many errors occur because of poor
communication. Ofri cites the first
case of ebola in the US, in 2014.
Thomas Eric Duncan, who had flown
to Texas from Liberia, went to Texas
Health Presbyterian Hospital in Dallas
feeling feverish and was sent away
with a prescription for antibiotics. His
travel history had been noted, but it
wasn’t passed on verbally or flagged
in the computer system. Duncan
returned to the hospital a few days
later and eventually died. Two nurses
who treated him were infected and
survived, and people he had come into
contact with had to be monitored.
“They weren’t actually talking to
each other,” Ofri says of the medical
staff at the hospital. “In the old days
we all sat together and could
communicate by actually talking. If
you look at malpractice data here in
the US, the vast majority of cases are
about communication.”
In her book Ofri examines the case
of a Kansas man who went to hospital
after suffering severe burns in an
accident. The nurse who examined
him said he should be transferred to a
specialist burns unit, but the ER doctor
disagreed. By the time wiser heads
prevailed and he was transferred the
next day, it was too late. He died
several days later. In the investigation
that followed, the nurse who had
initially said that he should go to the
specialist unit stated that she would
“never go against what a doctor said”.
“The hierarchy still exists, in some
places worse than others,” Ofri says.
“I think there is an ego issue, for a
doctor to be questioned by
someone lower on the totem pole.
Whether it’s a nurse or a family
member, or a patient, some
doctors don’t take that well. A lot
of us have trouble accepting that
maybe we don’t know what’s going
on. It’s very hard to admit our
frailties and foibles.”
In the vast majority of cases
where doctors do harm there is no
intent, Ofri says. But she suggests that
it may have been a culture of
hierarchy and impunity that led to
Simon Bramhall, a surgeon at the
Danielle Ofri
symptom “will come back to bite me.
We’re flying blind so much of the time,
and it’s really terrifying in terms of
making a mistake and/or getting sued.”
Ofri was not sued over the missed
multiple myeloma case, and it is
impossible to say whether the woman
would have lived longer had the
condition been spotted earlier. “We
only have the retrospectoscope, which
is very blurry.”
Ofri refers to the “20-plates-
spinning-in-the-air reality of modern
medicine”, when doctors don’t have
enough time to think. She once had a
“near-miss” when she failed to detect
a patient’s intracranial bleed. Someone
had told her verbally, “Radiology fine,”
so she didn’t look at the patient’s CT
scan. Fortunately, another doctor
spotted the bleed and the patient was
operated on and survived. Ofri was so
ashamed that she had put her patient’s
life at risk that she didn’t tell anyone
what had happened for 20 years. “You
don’t necessarily have the time to
read every lab report. I rely on
verbal reports all the time, just
waiting for disaster to happen.”
In today’s clinic she had to
spend an hour — which she
will have to make up at the
end of the day — with a
patient explaining, with
the help of a translator,
how he should take his
medication. “If I had an
hour per patient I’d be a
fantastic doctor and we
would make far fewer errors.
We’re so rushed at work. Our
thinking process is not clear, it
is cluttered and bombarded.
You wouldn’t want someone
Queen Elizabeth Hospital in
Birmingham, branding his initials
on the livers of two patients during
transplants in 2013. His initials were
discovered on a patient’s liver that
had to be removed because of
complications. He admitted to two
charges of “assault by beating”, was
fined £10,000 and had to undertake
120 hours of community service. “He
seemed to get off with just a little slap
on the wrist. Unbelievable,” Ofri says.
Technology can help conscientious
doctors to avoid mistakes, but
sometimes they pay attention to what
the computers are saying and fail to
actually look at the patient, Ofri
suggests. And medics can be so
overwhelmed by the amount of data
available that they are unable to see
the wood for the trees. Wading
through computer alerts on drug
interactions with alcohol wipes or
pregnancy warnings for 70-year-olds
is time-consuming and appears to be
more about avoiding liability than
providing patient care.
An investigation by The Boston Globe
found that more than 200 deaths over
five years were related to alarm fatigue,
which occurs when the cacophony
from medical machines is so loud that
nurses become desensitised to many
of the signals. At the height of the
Covid-19 pandemic, when a range of
new and different ventilators were
being used at Ofri’s hospital, the alarm
problem was acute. “Everything was
beeping and ringing and nobody could
keep track of what was real and what
was just noise,” she says.
Plenty of mistakes have occurred in
New York recently. “Covid tended to
hit our Latino population more
heavily, so we had lots of patients with
the same common last name, in the
same ward, with the same diagnosis
and the same treatment,” Ofri says.
“There were a lot of mix-ups.”
She suggests that doctors be given
longer slots with patients and argues
that now is exactly the time for medics
to push for a rethink.
“Doctors and nurses and healthcare
workers were suddenly seen as
respected, trusted figures. And we
need to be aggressively using that
capital. March and April here were
like building the airplane while you’re
flying it. All these things we thought
couldn’t change are changeable. Why
can’t we do more of it?”
Key to that is creating a culture in
which doctors feel able to own up to
their mistakes without retribution.
Ofri admires the approach in
Denmark, where anyone in healthcare
can report an adverse incident to
help to improve the system. The
information is not used for complaints
or litigation.
Ofri is full of little suggestions and
ideas, including making bed rails out
of antimicrobial metals such as copper,
and privacy curtains from material that
is inhospitable to micro-organisms. She
has some useful tips too for patients
looking to help doctors to avoid
making mistakes, starting with
knowing your medical history and
carrying it on a single sheet of paper.
If your doctor says, “I think you
have X,” always ask, “What makes you
think so?” Then, “Is there anything
else it could be?” and “Is there
anything we can’t afford to miss?”
Those questions might just prompt a
doctor to make the extra check that
finds that lurking cancer.
When We Do Harm: A Doctor
Confronts Medical Error by Danielle
Ofri (£22.50, Beacon Press)GETTY IMAGES