On-call, where the stakes are high
By: Ahmed S. Farghal
Tags: Birth, On Call, Production, Doctor On Call, DevOps

The consultants decided that it would be best to use induce labour, my wife has also requested to get epidural anaesthetic injection during delivery to manage the pain.

That night, the atmosphere was tense, we were told that because our first boy’s delivery was a c-section, the vaginal delivery might be challenging but still preferred. So, during that night we were a bit stressed and anxious but the midwives and doctors were always calm and comforting. They understood what my wife and I are going through and I can’t stress enough on how their attitude helped us through the journey.

Now, why I’m telling that story?

In my day job, I work with complex computer systems. Often handling the creative ways that distributed systems choose to fail at large scale. I frequently get to be on-call and when I’m not, you will find me often helping the current on-calls to restore the service. One of the things I constantly think about is how to improve the on-call experience.

What happened next during these early hours of the delivery day taught me a lot about how the NHS (National Healthcare System) staff are trained to handle incidents and emergencies. The NHS was once ranked ‘number one’ health system. I looked at the experience with critical eyes and noticed the subtle details that make this system reliable and efficient. We, as engineers, usually don’t handle high-stake incidents like how the NHS staff do. But nevertheless, there are plenty of lessons to be learned.

Logging and monitoring

Photo by Jair Lázaro on Unsplash

The day before we were moved to the Labour ward, my wife was being prepared in the maternity ward. The midwives’ protocol during that period was to do periodic observations (aka. Obs). She would show up every hour with a mobile computer with probes to get a strand of data points for the vitals metrics. Things like blood pressure, mum’s heartbeat, baby’s heartbeat, temperature, oxygen levels, etc. That data was automatically logged to a central system.

Low blood pressure was the common concern that the midwives noticed during that day as my wife’s steady-state blood pressure is lower than average.

When we were moved to the Labour ward, the observations were switched to continuous, she remained connected to the monitor for over 12 hours.

In the Labour ward, we got to have a private room. Each room in the ward had its own resident midwife that is responsible for a single patient, often writing her observations, actions, and even the patient’s feelings!

At first, I was a bit surprised by the level of details and the time she would put into inputting these details. As we started seeing a different midwife every 8 hours, it became clear to me why this is crucial. Each one would seamlessly pick up from where the last one left off.

Empathy

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There was a clear pattern on how the midwives and doctors communicate with us.

They usually start with a heart-warming smile. Then they would introduce themselves with their name, job, and responsibility. Then they would ask whether it’s good time for us to do whatever they are here for (which we probably will always do). The question is merely crafted to give you the feeling that you are in control. They might also give you an idea of how long it’s going to take them.

They will start telling you what happened with you so far, basically, telling you what you already know about your experience up until now. Then they would explain what will happen next and a timeline to set your expectations, if this is possible.

Let’s break down why their well-exercised style of communication is effective:

The smile; that is the first cue for empathy and care. It gives you the signal that everything is under control. The order; the introduction is designed to address the natural order of things that come to your mind. Who is this person, what do they do, why are they here. Reiterating the history; replaying the history to you is crucial, it’s an effective way of establishing trust. That complete stranger suddenly becomes trustworthy and you immediately open up to them.

The emergency button

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About two hours after midnight, the on-call anesthesiologist showed up with the epidural and the infusion pump. The anaesthesiologist verified that all “obs” look normal, then asked a few questions about allergies. He started programming the pump with the regular dosage after plugging the tube to the cannula he injected through my wife’s lower back.

After this, the resident midwife, me, and my wife were in the room observing the labour contractions as they intensifed and prolonged. Things were looking perfectly fine until my wife called out for help.

She was fainting!

I immediately alerted the midwife about the situation, she promptly started looking at the “obs”, a second later, the monitor started beeping as the blood pressure measurement started showing that it’s getting critically low. The midwife immediately told me to pull the emergency button, which was an obvious red pull button with “emergency” written on top. I noticed a label that reads “if you are not sure if it’s an emergency, then it’s an emergency, pull the button!”

I pulled the emergency button!

The next few minutes is when I got a chance to witness how the NHS staff were trained to handle incidents like these.

The button started flashing and I could hear an alarm sound beeping outside the room. The room itself was quiet so that whoever is in the room could remain calm. The resident midwife was following a specific emergency protocol, taking note of the time, reprogramming the monitor to do more frequent blood pressure tests.

Outside the room, I could hear the firm voice of the midwife-in-charge. She was ensuring that the response team is ready. About five seconds after pulling the button, the door was open.

The response team showed up!

Responding to the emergency

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In these five seconds, a team of about six people grouped outside the room and was then let in by the midwife-in-charge. The ones I could recognise were the consultant obstetrician and his trainee (shadowing), three midwives, and the on-call anesthesiologist.

They immediately lined up, and each of them appeared to have a specific goal. The obstetrician was asking the midwife questions to know what happened and was looking at the historical data. The midwives were assisting, and each of them was able to quickly identify whether they were helpful or not. At the same time, the anaesthesiologist literally jumped across my wife’s bed. Picking out a pre-prepared syringe out of his pocket and jamming it into the cannula.

She immediately started feeling better!

The blood pressure started showing improvement. The anaesthesiologist concluded that the epidural is the root cause. So he halved the dosage through the preprogrammed infusion pump. That was the point of relief for me.

By this time, only the anesthesiologist and the midwife-in-charge were present. The rest left the room as they recognised that they would not be helpful anymore, it was better to leave the scene to those who had the relevant expertise to address the issue.

The anaesthesiologist remained for a few more minutes until the situation looked like it’s getting consistently better. He explained to me why this has happened and that there is nothing to worry about.

The whole emergency handling happened within a minute or so, from what the heck is going on, collecting the team, root causing, and deploying mitigation. All in a self-coordinated setup. Quite impressive!

Incident tracking

After identifying the root cause and deploying mitigation. The midwife-in-charge devised, with the resident midwife, a plan to track the status after the incident.

The plan was to establish a full hour strand of vital metrics that don’t show any major anomalies in all the obs before they can consider the incident over. If everything is fine, they will use another injection to accelerate the induction. She started executing on this, every thirty minutes she would go and call another midwife to do what she referred to as the “Fresh eyes check”.

She would bring the other midwife to the room and together they would review the thirty minutes worth of charts and data. They'd discuss if things look normal or not, the second midwife would then draw a vertical line at the end of the thirty minutes period on the charts and sign that things look normal with her signature.

The fresh-eyes check ensures that the observations interpretation is well-thought and not biased. This out-of-band verification removes the bias and brings new ideas and suggestions to the table. An extremely helpful technique in situations like these.

After a couple of hours, the midwife-in-charge signed off that they should proceed with the injection. Things were looking positive at this point and all of them agreed. Although we had another incident during that night, the behaviour and situation handling didn’t change much so I won’t mention these.

Documentation

After the incident, as things calmed down, the resident midwife immediately switched to documentation mode. She inputted detailed documentation about what happened during the incident, how long it took, who was present and how they contributed. She also built a spreadsheet with key vital readings during the incident recorded every five minutes.

She even documented how the my wife felt, even when and how did I help. In the end, there was comprehensive documentation of everything they would need to do post-mortem analysis.

Can we learn something?

For the majority of us, we have on-call rotations with much lower stakes, watching the on-calls from a completely different domain at which the stakes are much higher and the staff training is world-class is an inspiring experience.

From logging, empathy, communication, incident management, to documentation. Each of us will find different angles in the story and how to learn from it. I am sure that you can build a set of actions to improve your on-call experience in your workplace based on your findings out of this story. Or at the very least, you might just simply admire and appreciate the details on how on-calls are done when stakes are high.

Huge thanks to Mosab Ibrahim, and Mohamed Bassem for reviewing and to Mohamed Sobhy for the comprehensive review and nitpicking.