Thread by @nosecglasses

1/11 My good deed for the week. A 🧵

Halfway through my endo list yesterday the DSU nurse came in.
“The last patient's arrived with his mother. He’s autistic and says he gets seizures when he is overstimulated.” She handed me his file. “There’s a letter from the neurologist”.

2. The neurologist said the ‘seizures’ came on with extreme pain/anxiety. The patient had been extensively investigated; there was no neurological basis for this problem; in the event of a ‘pseudoseizure’ the advice was “do not give anticonvulsants; the episode will quickly pass”

3. I went to see the patient preop: a young man in his 20's, a little unkempt but alert, oriented, polite, very intelligent, accompanied by his mother. He said he’d had multiple anaesthetics in the past, and that with each hospital admission he’d suffered at least one seizure.

4. "Staff didn’t seem to think they were serious". They obviously distressed both him and his mother greatly. I asked what he thought brought them on. "I don’t know – feeling overwhelmed, maybe?". I asked if injections or cannulas brought them on. "No, I’m fine with needles".

5. I told him my job was make sure he was safe, that I had a plan, and that I would walk him through every step to see what he and his mum thought, and ‘so that there'd be no surprises’. They seemed to like it, so I told them I needed a few minutes to get things ready.

6. I went back to the endoscopy room and got the whole team together for a briefing. I asked for all the lights to be dimmed, blinds closed, and all unnecessary alarms muted.

7. I asked them to prepare and position in advance whatever equipment was needed, because as soon as the patient was wheeled in, the room needed to be ‘Below Ten’. (Also known as 'Sterile Cockpit')

8. 'Below Ten' meant not only that everyone and everything needed to be quiet; it meant everyone in the room needed to focus on and support the critical task - in this case, anaesthetic induction until the patient was asleep and the airway secure. They agreed, got the room ready.

9. We wheeled the patient into the room:
"Hi everyone, we're Below Ten".
We could still see, but my reg inserted the cannula under iPhone light.
Monitoring was applied without sound off.
HFNO, a little midazolam and fentanyl, slow propofol infusion, and he drifted off to sleep.

10. Once I was happy with the airway:
"Thanks everyone, we're Above Ten".
Lights up, alarms on.
Gastroscopy done without incident.
At the end "Ok folks, we're Below Ten again".
Lights down, alarms muted, silent emergence in the room.
He awoke calm and happy, we took him to PACU.

11. Later he said to me – “Please write down for me what you did. It was the best hospital experience I’ve ever had. You’re the first doctor who’s ever believed me.”

**Everything we do is sociotechnical.**