I often hear how testing is part of life. I even use that, or related references, myself. Over the past few days I’ve been able to observe life and testing intersecting in a setting that is not part of my “everyday life”. This story starts at 12:30am, Saturday morning. My Wife wakes me up complaining of pain that is radiating into her chest. It is a heavy pain. We have a local service where we can phone a doctor for an after hours visit. This is proposed, I decide not.
Heuristic – this could be a heart attack. I can’t guess here. Criticality is high, the consequences of a bad call could be extreme. Therefore an unknown wait time for a doctor is pushed to one side.
I place a call, an ambulance is dispatched. Now I’m being coached by the dispatcher. Suddenly I’m part of a team. I’m being asked questions, I’m providing responses. Then I’m rummaging through our drugs cabinet looking for asprin. It strikes me that I’m suddenly part of a new team, we are, for all intents and purposes, pair testing. We are not sitting in the same location but we are working together, looking for signs that might give specific clues about what is going on.
Models – the dispatcher is building a model through our convesation, looking for certain key attributes of a problem. There were some indicators that this was not a heart attack but, at no time, was it dismissed. The possibility remained until proven otherwise through evidence.
The Paramedics that came to our place were incredible. One immediately went to my wife, the other stayed slightly distant. The one that went to my wife worked patiently and methodically through a list of questions. Blood pressure taken, pads attached and heart monitor engaged. Drugs for pain relief. Thinking back on this the Paramedics teamwork reminded me of airline pilots. One flying the aircraft, the other controlling communications but always as a team. When you are asking questions, hooking up machines you can’t really observe, but your buddy standing off a little can. This is important information that can be shared to benefit your patient. This reminded me of the notion of critical distance and its importance.
My wife and I received a “report” from the Paramedics. “We don’t think this is a heart attack but we can’t be completely sure. We suggest we take you to a hospital with a cardiac unit”
Through all this I failed to observe any detailed lists (Paramedic “test cases”) but I did observe lots of discussion, cross checking of ideas, checklists and medical attention. Each question was an experiment designed to reveal new information and a better understanding. We also got useful, easy to understand feedback (we could think of this as a test report) that gave us information upon which we could make choices. Risk assessment activities and risk mitigation options were quite evident.
The decision to go to hospital wasn’t a difficult one. What followed was a night in a major hospitals emergency department and a battery of tests. The handover in this situation, from Paramedics to Hospital, is interesting. Short, sharp, focussed, clear. The essential facts. History of the situation and what treatment has been given. It’s clear this has been done before but it is also clear that this process is about passing important information quickly so the patient can be given high quality care quickly. This process is lean.
The tests managed to rule out a heart attack but they were unable to identify the specific source of pain . I’m sure they had theories but access to tests that would assist diagnosis were not available at the time. We were issued with a letter to enable the other tests to be run two days later. We left the hospital knowing there was an undetected “bug” but, with a belief that the issue was not life threatening.
Lots of tests and checks were run during our 8 hours in Emergency. It’s a good reminder that tests can be quite specific to highlighting specific problems. While heart problems were ruled out those same tests could not determine the actual problem. Determining the best tests for the context is critical to success. Makes me think about the execution of test cases “because we always run them” or similar reasons.
Let’s skip forward about 36 hours. We have another large hospital within 10 minutes of our house. We are sitting in its Emergency Department. The pain my wife has been suffering has escalated significantly. The yet to be diagnosed “bug” has made its presence known and its severity has increased. The Triage Nurse goes through a series of checks, establishes history. We are pushed through to a treatment room in no time at all. It’s familiar territory, questions from doctors and nurses, establishing vital statistics, ECG, blood tests.
Even though the previous trip to hospital ruled out heart problems the searing, intense pain pushing into the chest, has doctors re-exploring this as primary concern. Given the really serious nature of a heart attack, reconfirming that a heart attack is not in progress, makes sense. Let’s not anchor to previous results when things might have changed and there are indications to support having another look. In a busy, stressful environment it could be easy to bias your investigations.
After a while the possibility of heart attack is again ruled out. That’s a relief bit there is clearly something amiss. Inspite of a massive dose of painkillers (including morphine) the pain remains extreme. The focus now moves to a gastrointestinal related issue. The tests change accordingly. A CT scan is organised, and there it is, the gall bladder is in a mess. The doctors want further details, confirmation and a basis on which they can figure out the best way to attack the problem. An ultra sound provides more evidence, further details about the specifics of the problem.
Now that testing has revealed the “bug” the process switches to an evidence gathering phase. What information can we gather to give us the best means of solving the problem? What other issues might there be? What do we need to prepare for? How will we know when we have been successful? How quickly do we need to move to optimise outcomes for the patient?
It turns out that good practice in this context is gall bladder removal using “key hole” surgery. The real interesting bit is that the surgeons felt it would be a good idea to have a look around while operating just to make sure there were no other issues that might not have shown up in the scans (or perhaps were hinted but not highlighted). I know about exploratory surgery as an approach, I’ve just never thought about it when the “bug” has been identified. As it turned out they found an umbilical hernia and repaired that as well.
Keeping your mind open to possibilities, drawing on past experience, heuristics, models, talking to colleagues can lead to the discovery of “off script surprises”. We didn’t expect this approach but getting that hernia fixed delighted us and represents a lot of value.
I have no doubt that as I reflect more on what has happened that I will discover more parallels and even find ideas to experiment with in my work. I cannot help but see the benefits of teamwork and open, clear communication. There were no signs of panic or rush. There was a lot of questioning, critical thinking, exploring options and making decisions using various forms of feedback. Many areas of software development seem to fight these becoming meaningful attributes. We really do need to examine and overcome the resistance. If hospitals operated like many software developers and spoke about these attributes but never really valued them….. I can’t imagine what the mortality rate might be.
What I saw in action looked a lot like Agile. Do doctors and nurses think of themselves as working in an agile manner or do they just do things that optimise quality of care and patient outcomes? Perhaps that is two ways of saying the same thing?
There are bad experiences and good experiences but each gives us the opportunity to take away things we can learn from. I think I’ll be debriefing, and learning from, this one for a while.
Finally – the magnificent work of a group of surgeons and nurses meant that my wife returned home less than 24 hours after surgery. Recovery is on track and we are all grateful for the expertise that, for the most part, we take for granted.
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