From Chaos to Stability

A couple of weeks ago I visited an Accident & Emergency service as a patient for the first time. For those of you who aren’t from the UK, A&E is where you’re taken by ambulance if you have an accident; it’s also where you can take yourself if something is urgently wrong. A&E services are provided by the National Health Service (NHS) and are located in (some) hospitals. 

Although I was really quite ill, I still managed to appreciate the experience; from an HSD perspective there was quite a lot to notice. 

One simple way of looking at my visit is by mapping it on the Landscape Diagram. The Landscape Diagram uses agreement and certainty as measures which create a landscape of different zones of system stability; HSD suggests ways we can shift the stability if we want to change how the system behaves. 

To use the diagram, we need to choose a container - or boundary (see Gareth Evans' article on the ethical implications of choosing boundaries). I’ll choose a container which I’ll call a “case” and look at how the actions of staff shift system stability as someone (me) makes a journey through A&E.

As I shuffle in through the front door of A&E, from a staff point of view I am a complete unknown. Agreement (about what is wrong with me and what should be done) and Certainty (about whether they will be able to help me) are both very low. I would place myself in the unstable / unorganised / chaotic part of the map of the Landscape. The staff’s first actions need to move me out of this zone, and they do this using some really tight (and very simple) exchanges. Reception asks me who I am and where I live, and puts my details into their computer system. This seems trivial but it does have an effect - I now exist in their world, they know they have to do something with me, and they know what the next step is.

Triage is the second exchange, which consists of a nurse asking me what’s wrong. This simple exchange actually reduces the difference in the container (of my journey) considerably: a whole host of conditions can be discounted and this edges me towards the central zone of the Landscape. I am no longer chaos walking, but something rather more tractable: I can be pulled into a medical process. They take my blood pressure and a sample for testing, and they insert a connection into my arm in case they want to plug me into a drip at some point.

Then a doctor arrives and asks me more detailed questions about my symptoms, plus a few things about my medical history. While we might think of this as “narrowing down” what’s wrong to focus the scope of action, in HSD terms it’s again reducing the degrees of difference within the chosen container.

The next thing that happens is pretty simple. I wait. By now I’ve been moved into a part of the hospital that’s focused on “major” cases (which I apparently am), and the activity around me is different. It’s quietly busy, and despite waiting being really uncomfortable, I realise after a while that it is actually part of a self-organising process. Given the variety of presenting conditions; the different sequences of examinations, tests and interventions that are being carried out; and the emerging knowledge of what each patient needs next, the staff have to self-organise to allocate available resources.

Since I’m poised on the edge of the emergent / self-organising zone of the Landscape now, this seems appropriate. They carry out one more test and then, at last, they intervene. At this point I’m reminded that, although we talk about diagnosis, we’re really in the business of Adaptive Action. The doctor makes this very clear when he says, “We’ll try X first and if that doesn’t work we’ll try Y, which usually does the trick. And if it doesn’t we’ll think about other options.”

In fact what happens is that we try X, which doesn’t work. Then we employ option Y, which also fails but leaves me exhausted and on a drip for a couple of hours. Then  we try X again, twice, and finally, I am given the option of going home and trying intervention Z - which is what I do.

Ideally, I would be in the stable / organised zone of the Landscape before they sent me home. There would be complete Agreement about what had happened and Certainty about the fact that it had been fixed and would stay fixed. The optimal route through A&E drives out all difference through a series of exchanges with the patient: the system shifts from being very unstable (from the medics’ point of view) through a stage in which new patterns emerge through adaptive treatment, and finally into a stable pattern of normal health - at which point the container of “case” disappears and the patient goes home. 

I’m quite well now, grateful for the professionalism and humour of the staff and for the speed at which I made it through the process. Actually I’m especially grateful for the humour: “Oooh,” one nurse said, when I told her what was wrong with me, “I had that when I was pregnant. It was terrible! I thought I was going to die!”