00:00:00: Welcome everyone. Welcome to part two of this episode,

00:00:04: "Complications and Endoscopy Discussion" with Dr. Srisahabar.

00:00:07: In part one, we discussed about the complications, what immediate actions one should take.

00:00:15: We discussed about consent process. We discussed about how to react during a delayed complication.

00:00:22: So, Srisah is joining us again today. We introduced him in the first episode.

00:00:26: He's a consultor gastroenterologist and director of endoscopy at Royal Stoke University Hospitals

00:00:31: and recently organized the first UK complications in endoscopy symposium. Welcome back, Srisah.

00:00:38: Thanks, Pramip. Thanks for being again here. Thank you. So, Srisah,

00:00:42: I want to take you back to the symposium. You rightly so, you invited some patients and

00:00:48: relatives who had experienced complications to talk about their experience.

00:00:54: And for our listeners, can you explain what would be patients' perspective with regards to

00:01:01: sort of the consent process and what would they like to know?

00:01:05: I think you briefly explained that towards the end of the first episode.

00:01:08: Maybe you can elaborate on that. Yeah, I think from the from the patients' point of view,

00:01:13: I think it's important for them to know why we are doing this. I think, as I said,

00:01:18: the indication is the most important. And I think as long as they know that this is the best option,

00:01:24: I think because we need to elaborate to them what are the options. And if they're aware that this

00:01:28: is the right indication, this is the best option. And irrespective of how complicated the procedure

00:01:35: is, most of the time the patients will accept that. And it's also important for us to elaborate

00:01:40: our experience as well. Sometimes now I do go to my patients, especially with ERCP, my

00:01:46: complication rate. I think maintaining your own personal data, your own unit data, your

00:01:53: organization data in detail and quoting them to the patients really helps them to develop

00:02:00: that trust between you and the patient. It's the fact that I think that is really important for,

00:02:06: especially like a procedures like ERCP as well. And in fact, over the years, our complication rate

00:02:12: has come down significantly compared to what the quoted complications has been in the studies.

00:02:17: And then the procedure complications discussion with the patient has to be appropriate for the

00:02:24: circumstances as well. Again, as we discussed in the last episode, the patient had other plans in

00:02:30: their life. And whether doing this procedure now is appropriate, or when you're quoting such high

00:02:37: complications, whether doing these procedures after that important life event is important,

00:02:43: you know, we have to have that discussion as well. For example, in the previous episode,

00:02:47: we discussed about whether the patient wanted to go on a cruise. And then I said, yes, you can,

00:02:53: but then the patient developed complication. But in hindsight, I should have said, you can go to

00:02:59: the cruise and then come back and then we'll do this procedure. Because if you have a potential

00:03:04: complications, then definitely you can't go on the cruise, which we have been planning for

00:03:08: the last two decades. I think it has to be tailored to the circumstance of the patient as well.

00:03:13: Yeah. And I want to stress that what's best option, what you think for the patient may not be the

00:03:21: same from the patient's perspective. For them, the best option or maybe a completely different

00:03:26: thing, you know, leaving the polyp all alone and live with the polyp rather than, I guess, you know,

00:03:32: or live with a stone, for example, I'm happy to take that risk rather than going through this.

00:03:36: So I think it should be very individual in that aspect.

00:03:40: Shrisha, early recognition of any delayed complication is important to improve the outcomes.

00:03:47: We talked about this earlier and our patients often present very late. And you mentioned something

00:03:52: about you put certain measures in place. You briefly mentioned some leaflets and things.

00:03:57: So what's your practice? What measures do you take or have in place to recognize these delayed

00:04:03: complications, the support the patients would get in case if that happens? So should you just

00:04:09: elaborate a little bit on that? Yeah, I think to prevent the what you say is a delayed complication.

00:04:15: As I mentioned that majority of the times these delayed complications are undecognized complications

00:04:21: at the time of the procedure or at the time of the recovery. So again, my practice has changed

00:04:28: because of the experiences I've had over the years. One of the things which I have learned is that if

00:04:33: you think something has gone wrong at the time as we discussed last time to doing something

00:04:39: endoscopic to Lee, even if you overdo it is the right way than not doing anything. For example,

00:04:45: you've done a polyp resection. You think hasn't gone a little bit deeper clipping at the time

00:04:51: itself will avoid sleepless nights and also potential delayed complication for the patient

00:04:57: rather than just nodding anything at all. For similarly, in an ERCP setting, a post-spin

00:05:03: trotomy perforation is very difficult to diagnose at the time as an echolonic perforation. And if

00:05:08: you think we've just gone a little bit more deeper, putting a fully covered metal stent in

00:05:13: is what we think is the right thing to do even it's a bit more expensive. So sometimes we think

00:05:17: that overdoing at the time of the procedure is much more better than not doing anything. Similarly,

00:05:24: doing recovery if the patient is still in complaining of discomfort, just dismissing it

00:05:29: saying that I think it should be fine when you go home in a day or two, it will settle down

00:05:33: is not a good option. Sometimes if you're worried about it, keeping the patient in the hospital,

00:05:38: getting a CT scan before they're going might be a better option. I think by doing these kind of

00:05:44: measures, and if you're really sure that the patient is completely fine and then giving the right

00:05:50: information to the patient about what are the potential complications which they can develop

00:05:55: and when they should contact the hospital or when they should go to the A&E immediately,

00:06:02: not delayed, I think those kind of discussions very, very important.

00:06:05: Yeah, so detailed post-procedure information is very important. Not all of us do that,

00:06:11: Shrisha. I think within the UK, I think we are guilty that some of us don't give full information

00:06:17: to our patients where and how to seek help. I've had patients go to their GP with melena post

00:06:25: polypectomy, which despite giving them information, for example, sometimes. So these things can

00:06:30: happen. So I think educating them properly is important. Shrisha, have you come across patient

00:06:38: dying after an endoscopic procedure, whether that is your procedure or your colleagues?

00:06:43: Tell us what happened. How was the situation managed after that and what are the things that go

00:06:49: through? That's probably the extreme end of what one can go through in this field.

00:06:57: Yeah, I think Pranip, especially for someone like me who has been majority of my work is

00:07:02: therapeutic procedures. Unfortunately, I have come across that not once, but in few occasions as well

00:07:09: when I take my complications, which happened with my trainee as well. So it's important here to say

00:07:15: that when it happens with a trainee, I am there. So it's my complications still. So I would say that

00:07:20: it's been few occasions when I've had that. But I think as we discussed earlier, I think in all

00:07:26: the situations when the indication has not been right is when you really struggle to deal with

00:07:31: things like this. So I think if you're prepared well, when you know that you did this for the

00:07:34: right purpose, then you have crossed one battle. And the next aspect is that having that communication

00:07:41: with your patient and the family right from the beginning, explaining them, being transparent

00:07:47: what has happened. And then as we discussed again, apologizing for what has happened is all very

00:07:53: crucial steps in your healing process as well. Again, we are all different. We all deal with

00:07:59: it differently. But for me, what's important is that once I've done all of this, I go into deeper

00:08:06: aspects of identifying, reflecting on the procedure and where I could have done things better.

00:08:14: And then I always seek for one or two learning points from every complications. And if I reflected

00:08:22: on it and I know that I'm going to apply it on it, then for me, that guilt and shame and all those

00:08:28: emotions disappears. I know in things like death happens, it will again, it will not haunt you,

00:08:34: but it will always be in the back of the mind where similar situations arise. But I don't dwell

00:08:39: on it more longer, because if I keep on dwelling on it, then that will affect my further procedures.

00:08:45: You can become risk aversion and I might not do the right decisions. So for me, the learning ends

00:08:52: once I've got the reflective points, and then I move on. Yeah. So do you have a process where

00:08:57: serious complications such as that is reviewed by let's say your colleague and kind of not as a

00:09:05: pointing blame or whatever, but as a learning process, if there was anything that could have

00:09:11: been done. And I'm sure mostly we would have done everything according to the best interest in mind,

00:09:19: but there may be an occasional learning point that we could have missed or we could have overlooked.

00:09:24: So do you always have asked one of your colleagues to go through this and

00:09:28: go through the case notes, for example, and see if there's any points to improve in such a serious

00:09:33: complication? Yes, I think this is a detailed process. I was talking earlier on my personal

00:09:39: journey on it, but obviously I get those learning points after a detailed discussion with my

00:09:45: colleagues and the team as well. And as you know, as part of the clinical governance, we have to do

00:09:49: that to make sure that we have a detailed discussion with the team. We used to have an

00:09:53: yearly meeting or once in six months meeting where we'd go through these complications in detail.

00:09:59: But now I think that's too late. We should disseminate that information, get those learning

00:10:04: points quite early on. What in especially in ERCP among our colleagues, what we are doing now is

00:10:10: that as soon as there is a complication, we get the team very quickly along and then go through

00:10:16: the complication in detail, put out our learning points, what I think I should have done better,

00:10:22: but then also ask them, is there anything which I haven't missed? Is there anything from your point

00:10:27: we should have done differently? And then make this as a team learning effort. And it's also

00:10:33: important that you disseminate this information wide as well. I think once we get one or two

00:10:38: learning points, there's no point just keeping it in. So there are several instances where in our

00:10:43: courses we have said we have had this complication and then there's so many of them said, yes, I have

00:10:48: seen this, I have seen this, but if we don't disseminate this information, unfortunately this

00:10:52: will happen somewhere else as well. Okay, we'll come to that a bit later. I want to talk.

00:10:57: about it towards the end of this discussion. Let's move on to the endoscopists. You alluded to

00:11:05: that we all deal with things very differently, it depends on our personalities. How does a

00:11:12: complication affect endoscopists as a person in terms of their performance, psychologically,

00:11:18: for example, and their future performance? How could you put measures in place if endoscopists

00:11:24: go through an extreme complication such as that or even a serious complication?

00:11:28: Yeah, I think as you said, we're all different and unfortunately for some people, this could

00:11:34: lead to increased stress, anxiety, the guilt, the shame, all comes in as well. And all of this can

00:11:42: make them lose their confidence, make them risk aversive. And unfortunately for some,

00:11:49: it can also stop them from doing the procedure as well. So I think the emotions can be varied,

00:11:56: but of all of this, the most dangerous people are those who don't have any insight at all.

00:12:03: I know there are people sometimes who it is a procedure which was a problem, or it was the

00:12:09: instruments which was a problem, or the nurses, or the patient, but never themselves. But most

00:12:14: importantly, I think majority of us, thankfully, lie in the other extreme wherein we are actually

00:12:20: reflective about, it affects us quite significantly. I think we still have that tendency that, yeah,

00:12:27: there is a complication in the list, and then we carry on, we crack on and start doing the next

00:12:32: procedure. You take about half an hour or 45 minutes, you deal with it and go move on.

00:12:39: But I think we have to change that attitude. People try to understand how much it has affected

00:12:44: them. So I think the best thing for the patients as well, if the complication happens, like somebody

00:12:49: else takes over the list, on that day, we don't do that, we should start doing that. And also,

00:12:55: the debriefing as well, even if it is a consultant colleague, having someone as a mentor to who can,

00:13:02: they can go and speak to them and discuss about the complications, very, very important.

00:13:08: So as for the trainees, again, we have to give that debriefing very, very well,

00:13:12: where is non-judgmental way. And then again, our clinical governance process, thankfully,

00:13:18: is changing, especially in the UK, where there was a root cause analysis before,

00:13:23: where in some amount of blame was placed on the individual. Now, the new clinical governance,

00:13:29: the patient's safety, what is called as a peace surf in the UK now, at least in theory,

00:13:36: is about not blame the individual, but look at the system and change the system. So

00:13:41: how will it is adopted and how well it will change the system without blame the individual,

00:13:45: we have to see. But I think the thought process should be on these lines to support the individual,

00:13:52: but also not blame the individual, but look at the system and processes,

00:13:55: which affects it and change them.

00:13:58: Hmm. As you mentioned about the invincible endoscopist, who's everything else is at fault,

00:14:04: except for him or her. Let's talk about the endoscopist in trouble. And those who have a pattern

00:14:09: of complications, multiple complications, as an organization or as a leader within your organization,

00:14:16: I don't want to put a blame on someone. You know, I guess people who do extremely complex

00:14:22: procedures by nature will come across more complications. The very nature that I remove

00:14:29: failed procedures or complex polyps does mean that I will have my higher burden of complications.

00:14:35: So we need to recognize that. But there are outliers within those fields. Either, you know,

00:14:42: you're choosing the wrong indication and you're doing wrong procedures, for example. And sometimes

00:14:47: it might just a bad luck in a series of events, one after the other. How do you recognize those?

00:14:54: What processes can be put in place within an organization to deal with such individuals?

00:15:00: Yeah, I think it's important when you look at that cases in detail, have a detailed discussion

00:15:05: among the team and identified what were the learning points as we discussed. And also,

00:15:10: when you're having the discussion with the individuals, even if there's a series of

00:15:14: complications, you know, whether this was something which was avoidable or was it just the nature of

00:15:19: the procedure where they had unfortunately a series of complications. But even if it happens,

00:15:24: series of complications when it was unavoidable, it affects the individual. I think it's very

00:15:30: important to support those individuals in those times, even if it was unintended, even if the

00:15:36: indications were appropriate, because it does affect them. And in fact, these individuals have

00:15:41: significant insight. And in fact, they want help. You know, any measures you put saying that, okay,

00:15:47: apart from debriefing, having supportive shoulders, offering them that why don't we do

00:15:53: a few procedures or a few lists together? I'm sure majority of the individuals who have insight

00:15:59: will accept that. But to say that I outliers are the ones who don't have an insight. And those are

00:16:05: the ones who will not accept measures like this, where in saying that why don't we do some supportive

00:16:10: lists? Why don't we do the list together? Why don't somebody observe you and then offer you support

00:16:17: and in fact, people who are outliers who don't have insight don't accept that. And in those

00:16:23: situations, I think it's very important that the organizations make every effort to make sure that

00:16:28: the patients are protected. So I think gathering all the information from your allied colleagues

00:16:33: and nurses will give you information as to how the individual is and your other colleagues as well.

00:16:39: So I think if required, we have to be rather than beating the bush. I think it's very important

00:16:44: the organization takes decisive actions in those times. We're not stopping the individuals from

00:16:49: doing the procedures. We are just saying that at this moment, I think probably you will not be given

00:16:55: this accessory for the time being, for example, an ESD knife or something else, until you do

00:17:01: a few procedures with your other colleagues. And then everyone is deemed that you are fit enough

00:17:07: to continue doing this. I think you have to put it in a much more diplomatic way. But at the same

00:17:12: time, the patients comes first. And in those situations, we have to take those efforts,

00:17:19: wherein even if you have to stop the procedure from the individual from doing the procedure for

00:17:23: that moment, we have to be very, very decisive on that. Yeah. So it's about putting that supportive

00:17:28: infrastructure rather than putting barriers on such individuals. Exactly. I think we can never

00:17:34: judge immediately in those situations. I think we should never be doing saying that you will never

00:17:38: do this again. I think that's not right. I think we have to provide them the supportive environment

00:17:44: to do that. But you might be able to convert, even though you call this outliers, with support.

00:17:49: Again, majority of the people will turn around. Humans are good and general. That's something

00:17:55: which we have to take it all. There are only very few individuals who come into that category,

00:18:00: what you call as an outlier, where we have to stop them from doing it completely.

00:18:04: Shrisha, trainees and complications. In brief, where does the responsibility rest?

00:18:09: Yeah, Pradeep. I think I've been very vocal on this. And I think the responsibility lies

00:18:14: completely on the trainer. I think we have to take complete responsibility on this. There's

00:18:18: no second thoughts on this. Shrisha, I just want to briefly talk about the symposium that you

00:18:23: organized recently. How did you get the idea? How did you go on choosing the content? And who did

00:18:29: you consult? And I found it very amazing. I think there should be a lot of future events like this.

00:18:35: As being part of a national society organization, how would you take things further in terms of

00:18:42: educating people, organizing such symposiums, let's say on a national level or an European level?

00:18:48: And have you already made some, if you want to reveal your secrets, made some progress in this

00:18:54: aspect? Now, I think this came about the thought about the complications symposium came about,

00:19:01: mainly from the discussion I was having from one of our national colleagues while we were having a

00:19:06: train journey together after meeting in London. So this is out in the open. So I can say that this

00:19:11: individual has had the situation wherein he was a national news and wherein he had four complications

00:19:19: and all the inquests were heard under media scrutiny. And so he asked me, is there an opportunity for

00:19:27: me to speak somewhere? And when all the aspects he mentioned about was all about positive things,

00:19:33: what support he got after all these events. And then that's when we decided that, oh, why don't we

00:19:38: put together a complications symposium, which would be very useful. And within about six weeks,

00:19:44: we designed the program mainly because of the support we had from many people I spoke to.

00:19:49: And thankfully, because of the BSE involvement and so on, we have got so many national

00:19:55: friends and then made a few traps and then showed it to them. And within six weeks, we had the program.

00:20:01: And then going forward, I think one thing we have to, which I've been saying is that we have to

00:20:06: normalize discussing complications. I think we, this should become a focus, we normally focus on

00:20:13: things, how to do well, how this procedure is done and how this technique is done very well.

00:20:19: But I think there's so much of learning from when things go wrong. And especially the new

00:20:24: procedures, we have to keep highlighting every procedure which has gone wrong. And that's when

00:20:31: we learn more from it. And my own personal journey, I can say that the more I've discussed my

00:20:36: complications, my procedures, my personal experience, my complications have gone lesser and lesser.

00:20:43: And I think that is what we should be doing nationally and internationally as well,

00:20:47: where complications should be a focus of every meeting and focus on when things go wrong.

00:20:53: We have already recorded from our complications symposium, and we have some ideas how to promote

00:20:59: this or to disseminate the information which we had from our symposium elsewhere as well.

00:21:03: But early days.

00:21:04: Lovely. I guess the big meetings like UVG Week should have probably half a day dedicated,

00:21:11: or maybe a separate symposium altogether at the European level would make. And I hope,

00:21:16: Shrisha, you will continue to do this yearly or by annual, I won't put one, say, every two years

00:21:21: or so. Shrisha, thanks for joining us so early today. I know it was 6.30 in the UK, and we both

00:21:28: have to go to work now. And thanks for your time and effort into the discussions. And I hope

00:21:36: our listeners benefited from all the discussions that we've had. Any final words before we wind this?

00:21:42: No, I just want to thank you, Pradeep and the UVG for making this topic a priority and

00:21:48: discussing this in detail. Thank you very much.

00:21:51: Thanks, everyone. We'll see you in the next episode.