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President’s Bulletin: You know you are in trouble when the floor shakes – why ERCP and safety matter

Updated on: 03 May 2022   First published on 03 May 2022

A group of flight attendants were hovering close to the toilet as I boarded a British Airways flight recently. The object of their attention, a gentleman in overalls, sporting an improbably yellow hazard vest and carrying an ominous green hose pipe, emerged from the right-hand toilet and announced to the assembled multitude, “you know you are in trouble when the floor shakes.”

This attracted my professional interest on several different levels. From a coloproctological viewpoint, I found it difficult to dispute his conclusions. From a purely personal objective, I hoped this was not a prognostic statement concerning the aeroplane’s “toilet worthiness”.

Meanwhile, a slightly large, but well-dressed lady, was staging her own personal battle, struggling to fit a dangerously large piece of allegedly “hand luggage,” into an overhead locker that was annoyingly non-elastic. The oft-heard instruction to, “open the locker carefully in case an object might fall out and cause injury,” was tempered by the suspicion that this object might cause more injury going into the locker than falling out.

Back at the toilet, there was a murmur of concern amongst the cabin crew.

“What does this mean?” demanded the Purser.

“It means”, replied Hazard Jacket with his hose pipe, “that your bearings have gone!”

The Purser looked visibly shaken.

“It’s your macerator” replied the engineer with just a hint of triumph. “It’s shaking the floor and not doing the job properly.” It was a deeply philosophical point. How many people could one mention, who metaphorically, “shake the floor”, but don’t do the job properly?

The respectable lady in the pashmina uttered a few dangerous grunts as her suitcase, its wheels wobbling threateningly, refused to enter the locker.

“Do I have a toilet?” demanded the Purser, slightly more loudly than she intended, and by now attracting the attention of the whole aft section of the plane.

“Yes,” said Hazard Jacket. “you have a toilet, and the plane will still fly, even if you have to cross your legs during the journey.”  Following this, he made his way somewhat lugubriously up the aisle, to where the lady with the pashmina was now breathing heavily and physically fighting the case, which continued to resist her best efforts.  “If you were a gentleman, you would help me,” she said.

The man with the hazard jacket sighed and with one deft movement tamed the suitcase and confined it to the locker.

“Thank you,” said the lady with the pashmina in a voice that sounded a little disingenuous. Hazard Jacket sighed and moved on, having unknowingly exacted a terrible revenge on the rude lady in cashmere. His hosepipe had been dripping quietly into her Burberry handbag.

The aviation industry has a justifiably good reputation for safety. Regardless of the toilet, I was confident that the plane would fly safely, and that if there had been an issue regarding safety, the Captain and the First Officer would not have allowed it to take off. In aviation, a plane crash generally kills a lot of people all at once, and the crew usually dies as well. As a result, they have a strong vested interest in preventing accidents.

Aeronautical engineers also take safety seriously. My father spent all of his working life in avionics and in 1963, led a team that developed the first fully automatic landing system in the world. He always referred to “Murphy’s Law”. The observation that, if something could be done wrongly, somebody eventually would do it.

In medicine, our errors of judgment can also result in injury or death. We do not crash a plane, but over a long career our errors can mount up. Unlike the flight crew, our patients suffer or can come to harm, but we don’t die with them.

Recently, there have been several Coroner’s Court rulings concerning ERCP. I do not want to highlight individual cases, except to note that many describe well-recognised complications. Nor is it unique to the United Kingdom.  A brief search on Google found Coroner’s Court rulings in the UK, Australia, and Ireland. Every kind of error is documented, from the operative to failing to spot or act on significantly raised results such as the amylase.  What is clear, however, is that it is rarely a simple operative error that attracts the attention of the coroner. It is usually an incident that is compounded by multiple system errors, that prevent the harm from being acted on promptly, and which, if avoided, might have prevented an adverse outcome.

The combination of human error compounded by system failure is well recognised in aviation too. There is often a naive belief that the solution to our professional problems is simply to become “like aviation”. Introduce a few checklists. Get people to sign for things. Endlessly repeat safety checks. All of these solutions have been tried in aviation, and on their own, they do not work. Simply intoning checklists like a liturgical chant does not improve safety, unless people pay attention and take responsibility. Training pilots to a high standard, but ignoring air traffic controllers, or maintenance engineers, does not make flying safe. Safety has to become a culture in which procedures are always done correctly, observations are acted on, and everyone, not just the Captain, knows their roles and their responsibilities.

Aviation is not the only model for safe practice. In medicine, emergency procedures have more in common with a group of firefighters entering a blazing building. They do not know what they will find, or how they will deal with it. A safety checklist may help prevent obvious errors, but it does not help them once they go through the door. Teamwork and watching out for each other, so that the team remains cohesive and focused, are what keep them safe, but also allow them to save lives.

We need to examine our practice.

This is not an admission that what we do is wrong, or unprofessional. Hundreds of thousands of safe, competent procedures are performed by British endoscopists every year, and tens of thousands of lives are saved. Wanting to do better, to make sure endoscopists are well trained, systems more resilient, and procedures safer is not an admission of failure. It is an aspiration to improve our care and to shift the metrics so that the whole curve moves to the right, and what is exemplary today becomes the norm in the future. The standard that everyone could reasonably expect.

We could start with consent and documenting our discussions with patients, straight away.

The BSG, through its endoscopy section and in conjunction with our colleagues in surgery and JAG, will make genuine efforts to raise the quality of our work. We have done it before with colonoscopy, so we can do it for ERCP, PEGs, and the multitude of other procedures we perform.

Some of the most detailed descriptions of recent ERCP misadventures appear on the websites of “no win, no fee” lawyers. It is understandable, therefore, that endoscopists feel threatened and can conclude that the sharks are circling. This is unfair to sharks.

It is said that statistically we are never more than 40 feet away from a rat. Rats thrive wherever there is rubbish. The best way to stop rats is to clean up the premises and eliminate the rubbish.  The best way to protect ourselves from litigation is to raise standards and develop a culture of safety. At the end of the day, medical negligence lawyers do not save any lives during their careers. Endoscopists do. All the time, every day of the week. So let us rise to the challenge and develop our own safety culture.

You know you are in trouble when the floor shakes, but we can do something about it.


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