The sound of running feet followed by a twang, a thump and then a crying child. These were the noises that grabbed my attention while I stoked the fires of our portable pizza oven at our Cornish campsite. Not the noises you want to hear while trying to relax on the last night of your holiday. First check – is it my child? No. Not good news though as it is my nephew, 7 years old, and he is not a happy chap. Dad (my brother-in-law) is quickly there, and we determine that he’s hurt his arm. Then I hear the inevitable, “Don’t worry, Uncle Jon is here, he can have a look at it.”

 

I think these scenarios present an interesting challenge for the GP. They are, on the one hand really difficult to manage, and on the other, really easy. They are difficult because it is really hard to give a confident diagnosis in this acute phase. As a GP you NEVER see someone with an injury which is only a few seconds old. We all know that children will cry when they fall over, whether there is a serious injury or not, and it is impossible to know in those first few minutes whether this is likely to be anything more serious than a bruise. In some respects the person most able to determine whether there is a problem or not is the parent, who does know how likely their child is to be crying like this with a minor injury. I suspect, however, that there is an expectation that you should know. That you should be able to instantly say whether something is broken or not, just by looking at it. It happens in the movies all the time after all. So, you feel immense pressure to be able to get this right, even though you know you probably can’t really tell.

 

In contrast, the scenario is easy to manage because what to do next is really simple – you watch and wait. If he calms down and starts moving his arm, you’re probably ok. If he doesn’t, then he needs an X-Ray.

 

He didn’t settle down.

 

He had spent a week participating in reasonably high risk activities. Body-boarding in reasonably rough seas, hard-core coasteering, climbing over rocks on the beach and cycling at high speed around the campsite. He broke his arm tripping over a guy rope. Isn’t that a lesson for life? We worry about the obvious, risky things, but fail to notice the simple ones. How often have you heard the same story about how people get injured? Occasionally it is from the high impact road traffic accident, but more frequently it is a simple trip or slip. I have been physically present 4 times when someone has had a fracture. Only on one of those occasions would I have predicted a fracture based on the level of injury.

 

So what is the lesson here? A couple of things I think. The first is that we need to be aware that it isn’t always the obvious, high risk items that will bring us crashing down, but often it is the less obvious issue that slips under the radar. As a CCG Clinical Chair I have spent more time dealing with things relating to issues like removal of sutures or irrigation for ear wax than you would imagine, yet I bet you would never have predicted this would be a major problem. When we run our risk assessments we rightly focus on the things that we can see looking ahead, but you don’t know what you don’t know (I’m sure you all remember Donald Rumsfeld’s famous quote on this[1]). I’m not suggesting we need to put everything onto our risk registers, but that we need to keep alert, keep our eyes open, and watch for any warning signs of problems we were not expecting. Game of Thrones fans might relate to this recent quote from the ever-sneaky Petyr Baelish, “Don’t fight in the North or the South. Fight every battle everywhere, always, in your mind. Everyone is your enemy, everyone is your friend. Every possible series of events is happening all at once. Live that way and nothing will surprise you. Everything that happens will be something that you’ve seen before.”

 

The second point I wish to make is related – we are poor judges of risk. We see risks in things that are relatively safe, and ignore risks where they are present. Participating in ‘high risk’ activities is often much safer than you imagine, because you take precautions and are alert to the danger. Meanwhile we are blind to the risks of everyday activities like driving or crossing the road. We also have a distorted view of the likelihood of disastrous events occurring. The media has heightened our sense of risk for terrorist events[2], plane crashes, murder, child abductions and other high profile scenarios, all of which remain, thankfully, relatively infrequent compared with car crashes[3] (for example). Not many people spend their lives worrying about having a car crash, however, but I suspect a good number are worrying about terrorism and considering avoiding places like London and Barcelona at the moment.

 

Our failure to properly understand and respond to risks also factors into our approach to medicine. Conversations between clinicians and patients too infrequently explore the risk-benefit ratios in question for treatment options, and we often perceive greater risks in our actions (whether this be starting or stopping therapy) as opposed to our inactions. There is also an increasing culture of ‘better safe than sorry’ and of wanting to investigate to eliminate all risk, without consideration that increasing investigation can increase medicalisation, ‘over-diagnosis’[4] and carry its own risks.

 

These are complex issues and far too overlooked.

 

So what do we need to do?

  1. Consider, inquire about and understand the risks that you face.
  2. Be aware that there are many unexpected things that could suddenly arise and cause you a problem.
  3. Try to keep your view of risks proportional to reality.
  4. Explore the risks of treatment options with your doctor, including the risk of not doing anything!

 

My nephew needed 3 hours in surgery and 4 wires to fix his fracture. He’s doing ok now though!

[1] https://en.wikipedia.org/wiki/There_are_known_knowns

[2] http://www.telegraph.co.uk/news/0/many-people-killed-terrorist-attacks-uk/

[3] https://www.gov.uk/government/publications/annual-road-fatalities

[4] http://www.preventingoverdiagnosis.net/?page_id=1176

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group
Follow Jonathan on Twitter @DrJonGriffiths

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