Large Fierce Mammal

This works just as well if you replace the word “patients” with “problems”. Source: Here

“There’s an old saying — “Safe as houses” — usually spoken in reference to situations that were anything but safe, but not always. There have forever been people who lived their lives in a wide eyed and blissful belief there can be some place where pain and death won’t find you.

“Enter the “safe space” which, interestingly, seems to be a phenomenon built by and for people of a vintage unaccustomed to the joys and perils to be found in working without a net.

“The modern societal shift toward “safety first” represents another case wherein the utterance elicits a nodding of heads and stroking of chins as if it stands axiomatic for living a fulfilled life. If risk represents any impingement on safety, then it must be avoided at all costs.

“Fie, I say.

“Musashi quite wisely said, “Do nothing which is of no use,” and with that in mind, I prefer a return to first principles — the safety of an enterprise MUST have no bearing on the worthiness of its pursuit. Only upon the manner of its execution. Even then, this will be governed on a sliding scale running between proceed with caution and damn the torpedoes, depending on the urgency placed upon achieving the objective.

“Any other mindset will see people peeing their pants in front of the door to the washroom labelled as most accommodating their genitalia while the one oppositely labeled stands vacant. Killed in a cross walk because the sign said “WALK”, so they did.

“The mantra of “safety first” is the kind of bullshit that, blindly accepted, puts someone else in charge of your safety so you don’t have to own it. So you can be the “victim” who must never be blamed but always believed.

“We teach our children to look both ways before crossing the street, not to avoid crossing streets altogether. Risk management is an industry term that, by its definition, represents a mindset recognizing that even though there are risks to life and limb inherent in an enterprise, they can be identified and if not circumvented, at least limited in scope or effect.

“Here’s another old saying for you — the cowards never started, and the weaklings died along the way. If the framing of that sentiment confuses or offends, go back to the top and read it all again.” ~ Risk: Nothing of Value Happens Without It, 27 May 2018

I have been a professional security consultant for 40 years, the practice of which covers a very broad spectrum indeed but simply put, what keeps the bills paid around here is protecting people, their endeavours, and the fruits thereof from two constants — themselves and the Dread Prophet Murphy, which more often than not amounts to the same thing.

You see, not unlike the cold eyed killer in a movie who forces his victim to dig their own grave at gunpoint, you should know that Murphy has a predilection for people willing to do his heavy lifting, which looks to them in practice not to be much like real work at all, let alone needful of any imminent existential threat for them to kick his entropic agenda down the road with joyous gusto. Do that long enough and you’ll become his indistinguishable twin, although you’ll be the last one to acknowledge it.

All you need do is take a look at the way people drive, cross streets, consume their poison of choice, and have sex to see that my job security is assured in perpetuity, or as close to that as I get before deciding to cash out on my Freedom 95 plan. Obvious or not to the untrained eye, those unsound proclivities are broadly endemic and so percolate into every other aspect of human endeavour. From the marvels of engineering one is assured can be trusted with not only your life but the lives of those who rightly look to you for their welfare, to the Grand Pronouncements flung down upon the heads of the Great Unwashed from the pinnacle of the loftiest ivory tower, modern society makes it easy to be more often wrong than right, and not only be lauded but make a damn fine living doing it.

One manifestation of this is “diagnostic momentum”, an unfortunately not atypical phenomenon in the practice of Troubleshooting that widely afflicts society to its core. One representative outcome of this from the practice of Medicine recently hit the news when after being taken by his Mother to three different Ontario hospitals, and in the process speaking to six physicians in less than a week, it was finally discovered that her Baby diagnosed with a sprain had actually suffered a stroke. When you read that news item in its entirety by clicking the immediately aforestated link as I know you will, two parts of it should stand out to you:

“Studies show misdiagnosis affects 10 to 15 per cent of people who arrive at hospital emergency departments, according to an emergency room doctor who has studied and written a book about diagnostic failure. Dr. Patrick Croskerry, who teaches at the Dalhousie School of Medicine in Halifax, says the most common ailments likely to be misdiagnosed in ERs are heart attacks, sepsis and stroke.”

And this attributed directly from Dr. Croskerry:

“‘People are working extraordinarily hard every day, and we know from the cognitive sciences literature that when people work hard, their decision-making is compromised,’ he told Go Public. He expects studies will be done once the COVID-19 crisis is over, to calculate the impact on emergency rooms. He said a negative effect seems ‘inevitable,’ due to the additional workload and stress created by the pandemic.

‘Talking to colleagues, it is clear that everyone is expecting it,’ he said.”

Let us now take the grim situation described in our example and run with it as the timely teachable moment that it is.

Let us say that a problem presents that inhibits operation of a system or process. The afflicted system or process may be an organizational structure built from a hierarchy of human resources (what I prefer to refer to as people), computer network, telecommunications infrastructure, power distribution grid, municipal storm sewers, the air handling systems in a building, a toilet that keeps backing up, anti-lock braking in a vehicle, a fruit bearing tree in your back yard, an incessantly barking Dog, or the nerves delivering sensation from your left big toe. All that matters is that a problem has been found to exist that must be resolved, and its resolution has been recognized by the organization, people, or person empowered to oversee the welfare of the technology, sewer, toilet, tree, Dog, or toe as exceeding the resources that may be effectively deployed in-house by it, them, him, or her. An outside professional must be called in. Enter the Troubleshooter and the initial consultation.

First, is there a real spanner in the gears or is the presence of one presumed as a matter of perception? Not to trivialize a floor awash in the effluent of an overflowing toilet and the obviously very real demand for a quick and effective solution that it represents, is the sky really falling or is there a flock of Canada Geese with splendidly synchronized cloacae passing overhead? Is there really a wolf or has somebody just found benefit in all the attention to be found in talking about it? Is the Client seeking to implement a brilliant solution to a problem that only exists within an ill conceived framework or environment of their own devising? This is a vital first step because any attempt to troubleshoot a problem of perception may produce real problems that never existed before and will of necessity come to consume their own share of resources. You can see how this leads to a slippery slope as new measures are introduced to solve the problems created by previous ones introduced because of an undesirable state of affairs that never really existed in the first place, or if it did, not in the way it was perceived.

A problem that passes initial consultation into the investigative phase will commonly find the Troubleshooter presented with these states of affairs, singly or in varying degrees of combination:

1. No one interviewed in the initial consultation will have sufficient knowledge of the afflicted system to actually know what its proper operation even looks like. For example, this happens in organizations where poorly planned restructuring or retirement from critical infrastructure management positions results in the maintenance version of a mass die off event.
2. The nature of the problem as reported by those afflicted by it will resemble that suggested by the symptoms found to exist to a degree ranging from no symptoms at all to symptoms bearing no resemblance whatsoever. This may indicate that there have been insider attempts to fix the problem leading to further attempts to fix the problems caused by the first fix, but most commonly it means that someone in higher authority has a pet theory on the cause so nobody lower down in the food chain will give voice to any observation that conflicts with it.
3. Functionality is unimpaired but the reported problem is the result of a loss of relevance of the afflicted system or process due to changes in environmental or operational parameters and/or realities it was never designed to function within. This should require no further example or elaboration.
4. A system that was working as intended has either progressively or suddenly diverged from optimal performance, presenting with one or more symptoms that may or may not be present upon initial examination. Such a problem is not unlike a painful but otherwise healthy tooth that stops hurting on the morning of your dental appointment.
5. A system that was working as intended has stopped working altogether, possibly as an outcome of 1 above where the symptoms were ignored, simply “lived with”, or redefined as the “new optimal” through a downward adjustment in expectations. Longevity programs implemented to keep aging military hardware in front line use run the risk of conforming to this classification.

Returning specifically to the baby boy in Ontario and the retrospective assessment of his case by the Good Dr. Croskerry, let me first categorically state that nothing that has preceded or follows this point is intended to cast aspersions generally upon his professional qualifications and accomplishments, nor to be specifically critical of his assessment as quoted above.

I am not a physician, but as my assessment that follows applies to matters under discussion I speak as one who is professionally qualified, skilled, and extensively experienced in Risk Assessment, Emergency and Disaster Contingency Planning for Municipal Governments as well as Hospitals and Long Term Care Homes, Incident Command, Emergency Communications, Emergency Management, and of course, Troubleshooting, which is universal; in its application.

As you will see as you read further, my assessment of the Ontario ER system and that of other such systems across the country is that they fit into category 3 above, with the caveat that functionality was far from unimpaired when the pandemic hit, and of course category 5 without reservation.

The experience of Sana Tayab-Mohammad and her son Uzair are an extreme but predictable and inevitably repeatable outcome of a rapidly worsening state of affairs. The funding, regulation, and delivery of health care services in Canada is a responsibility of Provincial governments, and in its failings, that of Ontario is far from unique in the country. The very real and growing performance challenges described by Dr. Croskerry as being experienced by ER doctors, and through them anyone seeking the services they are in place to provide, had their genesis well before anyone ever heard of COVID-19 and can be accurately said of every Province and Territory, predominantly due to long identified inadequacies in funding.

Long before the current pandemic began in my own home province of Nova Scotia, a growing shortage of family doctors had led inexorably to a closing of practices to acceptance of new patients, and a compensatory resorting by the population to the nearest ER for even non-emergency medical aid. Even those who were long standing patients of their own family physician often came to find themselves encouraged by reception staff to go to the ER if their problem couldn’t wait the weeks, sometimes months, it would take to get an office appointment.

For patients in Nova Scotia’s south shore where I live, there are three hospitals, listed here in descending order of size and capacity:

• South Shore Regional in the Town of Bridgewater (the largest);
• Fishermen’s Memorial in the Town of Lunenburg; and
• Queens General in the Town of Liverpool.

While in the beginning, people tended to take their matters to their nearest hospital, as ER wait times increased under the demand, word soon got out that what had become an hours long lineup at the larger South Shore Regional Hospital ER could be avoided by going to one of the smaller and heretofore lightly loaded facilities a 30 to 45 minute drive away.

Not surprisingly, with staffing at the smaller ER’s being designed to accommodate historical demand, they too soon came to overloaded by this new development, and the problem of long wait times became the norm.

With the common use of hospital ER doctors as a substitute for a family physician came another complicating development as expectations of equivalence between the two areas of practice erroneously grew, for the most part absent contest, in the minds of the public. Unlike a family physician, the ER doctor has no continuity of knowledge for any given patient unless by some stroke of fortune they are acquainted for reasons other than the ER encounter. In a majority of cases due to a combination of the their duty schedule and the randomness of visits by any given patient, an ER doctor is unlikely to see even a regular visitor to their work place on consecutive visits. This is no impediment to performance as long as the ER doctor is operating within his or her tasking in that role — to examine, diagnose, provide immediate treatment, and move a patient out of the ER to make room for another. This may be to home, admission to hospital, or something else, but the point of the exercise is not long term continuity of care, and operating ER facilities as though the distinction doesn’t matter is a ticket to disaster. One among many symptoms of which just happened to be extreme enough to hit the news.

This evolution of ER’s into providers of general medical service made them pinch points and areas of friction that inhibit their intended functions, all without increases in staffing. Overwork and fatigue not only affect judgement but also inhibit patience — people, even very competent and experienced physicians, get cranky. Add to this a frustrated patient who has been simmering in pain for six hours in an uncomfortable and ill-heated ER waiting room chair, or worse a frightened parent who has been desperately trying to get medical aid for their young child, been repeatedly blown off as trivial for reasons that don’t match her own knowledge of his condition, and just won’t take no for an answer so keeps coming back, the potential increases for “chart lore” (see the picture at the top of this article) to take the wheel, branding her by her understandable demeanour as “one of those” parents.

While the news coverage makes no overt mention of it, the negative effects of COVID-19 on front line medical staff and the patients they serve every day, their quality of interactions and outcomes, has far less to do with effectively stemming a tsunami of infected patients that will overwhelm these rickety systems than it does the life sucking consequences of labouring daily under workplace policies square pegged into the round holes of Canadian Emergency Rooms. And it doesn’t stop there as regular physicians and specialists watch their patients face unnecessary suffering or death from treatable conditions due to the same sorts of COVID-19 justified restraints. For example:

“Dr. Sheila Singh is used to explaining complex medical situations in simple terms. The pediatric neurosurgeon at McMaster Children’s Hospital in Hamilton says that lately, she’s seeing too many oranges and grapefruits and fewer ping pong balls.

“That’s not good, and it could signal that the COVID-19 pandemic has delayed the diagnosis of many pediatric diseases, sometimes with devastating results.

“‘You can imagine a tumour that’s the size of a ping pong ball, it’s easier for me to work around and remove it,’ she said. ‘But if that ping pong ball-sized tumour grows to the size of an orange or a grapefruit, the tumour has grown to a size where it’s much more difficult now to deal with’ …

“Singh says she believes the delays in diagnosis have been caused by patients staying away from hospitals because:

• They are afraid of catching COVID-19.
• There is a lack of in-person visits with their family doctor.
• There is an anchor bias to look for COVID-19 symptoms to the detriment of flagging other serious diseases.

“‘There’s no doubt there will be collateral damage,’ she said, ‘and some of that will be death and poor outcomes from diseases that could have had better outcomes.'” ~ Late diagnosis of tumours in children collateral damage of COVID-19, doctors say

While I can identify broader causes for the problems we’ve looked at today, they are, I believe, irrelevant to the problem under discussion for which the resolution will only be found when thinking on the pandemic becomes less linear and more systems oriented, something highlighted when the CBC article says of Dr. Croskerry, “He expects studies will be done once the COVID-19 crisis is over, to calculate the impact on emergency rooms,” and that, “He said a negative effect seems ‘inevitable,’ due to the additional workload and stress created by the pandemic,”

We need to stop thinking no further than a theoretical day when, “… the COVID-19 crisis is over …” and look instead at how our systems and their supporting policies need to be reconfigured to work the way they need to whether it ends or not. Anything less is as effective as a New Year’s resolution, and as I wrote of that upon the New Year’s Eve of 2014:

“By now, those disposed to it will have proclaimed their ‘resolution’ for the “new year”. They may have proclaimed more than one. From there, as with all such things, the outcome will be, as we say, fuck all. How do I know this with such certainty? Well now Goode Reader, the answer is obvious, and lies in plain sight in the words ‘New Year’s resolution’.

“One may successfully silence an incessantly barking Dog by means of a collar that administers an electric shock when the sound of a bark is detected, but without foreknowledge of what has motivated the Dog to bark so much, only the outwardly expressed symptom is erased while the reason for it remains. Remains to manifest in more destructive and toxic ways.

“One may have grown dissatisfied with one’s appearance as it has changed over time, and become caught up in squandering time, thought, and treasure in a fruitless battle to recapture a fondly remembered moment of perfection, and hold it in stasis forever. A moment of perfection that never existed; for perfection, for each of us, is not a thing that existed once upon a time, but in the moment that is now, and if you can’t find it there, you won’t find it anywhere.

“When one gets on an airplane, it is with no need to state an attendant intention to eventually get off of it. So it is that “going on a diet” is like going on a trip – the act comes with the presumption that when a specific goal is reached, the activity will end, even if the perceived necessity for the diet, or trip, is born of misfortune of the traveller’s own making.

“All ‘New Year’s resolutions’ will fail because they are born of procrastination, and those self-deluding sods who proclaim and embrace the concept trumpet their lack of resolve by the simple act of putting off all their life changing actions for one magical day. A magical day that, like tomorrow, never comes, because in the end there’s always another New Year, right?

“Wrong. Find the moment and your perfection in it.”