In Middlemore Emergency Department in the 1990s we introduced lightning packs. Their first use was in extreme emergencies, when we wished to rush a patient from ambulance to resuscitation room, and to medical or surgical intervention, with absolutely no delay. The pack was an envelope containing a form in triplicate to serve as a handwritten clinical record, an array of x-ray and laboratory investigation request forms, principally biochemistry and haematology, an accompanying array of specimen bottles, and a hospital identification wrist-band. The pack, the wrist band and all the other articles were tagged with a “sticky label” which shared the same unique hospital patient identification number. Thus an unknown unnamed patient could be identified by his or her unique number and the task of recording patient demographics could be deferred.
We thought we would only use lightning packs occasionally but they were seen to be immediately useful in a variety of situations. For example it was clear that they would be invaluable if a major incident unfolded and the department received a sudden influx of a large number of patients. They became an integral part of the hospital’s Disaster Plan. Initially we held 150 packs in readiness. We had a low threshold for using a pack in an isolated situation because it was essential that all clinical and clerical staff be familiar with the packs and how to use them.
Then the digital world, the world of the internet and email and information technology erupted, and it became clear that the process of becoming more electronic while going paper-light would be inexorable. But the lightning packs became all the more important to us. The systems at the front desk kept crashing. The front desk would revert to paper, pen and ink, but if we were in a hurry we would just use a lightning pack. We increased the number of packs held in readiness so that if the lights went out we had a system that could identify and track a 24 hour patient load. The system was low-tech and that was its power. It could not be sabotaged.
I thought of lightning packs in May last year when NHS Scotland was targeted by hackers who disrupted IT systems and demanded ransom in Bitcoin. The attack was named “WannaCry”. Another attack, “BitPaymer”, was launched in August. It came in the form of a piece of spam email. On both occasions patient appointments and procedures were cancelled. As a result, much money was spent shoring up cyber defences, and more cyber security specialists were recruited.
Now I read in the Sunday Herald that the UK’s National Cyber Security Centre (NCSC) are warning of the possibility of future state-sponsored offensive operations.
Computing power is now very important in clinical medicine. You can’t run a CT or an MRI scanner without computing power. That is why it is vital that these systems be quarantined from any potentially malignant outside influence. But aside from that, there are sound reasons why a Health Service of all things should be particularly robust in the face of a cyber-attack. In order to function, doctors and nurses might find computers, at least when they work, a convenience, but fundamentally, they are not really needed. In terms of the trafficking of information they don’t serve any function that can’t be fulfilled by paper and pencil and a telephone. The beauty of the diagnostic medical consultation is that it relies mostly on the knowledge, skill, wisdom and kindness of the attending physician. I can’t think of a reason on earth why any general practice or hospital department should cease to function simply because the computers have crashed. All it takes is for the clinicians to put their heads together and come up with a low-tech plan and a modus operandi for working under such conditions. Make up some lightning packs and stay open for business.
Meanwhile today’s (Monday) Herald front page is dominated by two headlines:
Protect workforce from the rise of robots, warn unions.
NHS staff taking early retirement doubles in eight years.
Scottish Health Secretary Shona Robison is under huge pressure just now. NHS Tayside (Ms Robison’s constituency) has come under fire over its use of charity cash to cover general running costs. This includes the financing of an IT project.
South of the border, I see that Jeremy Hunt is warning the big Social Media empires that if they don’t do something to sort the content on their respective platforms that is damaging the mental health of young people, he will step in and do it for them.
Most people will take a nuanced approach towards the digital world and say that there is nothing intrinsically good or bad about it; it all depends how you use it. I suppose I must agree with that; why else would I write this document on Word and then post it on my blog? Yet sometimes I wonder. I’m beginning to think there is something inherently malevolent about this Brave New World in which we find ourselves. Clearly we are not in control of it. Like the Sorcerer’s Apprentice, we are floundering. It seems to me that IT is a bit like alcohol. It might be safe and even beneficial in small doses. (Actually the medical profession is now even questioning that.) But take too much of it and it will destroy you. Remember Tiger Tanaka’s remark to Mr Bond in You Only Live Twice concerning saké, that the man drinks the first flask, the second flask drinks the first, then the saké drinks the man. That truth must be recognised cross-culturally because it is almost exactly replicated in a proverb in Scottish Gaelic which roughly translated says, “One drink: the better of it; two drinks: not the better of it; three drinks: the worst of it!”
So it is with the lap top and the tablet and the desk top. Remember, you always have the option of switching the contraption off. I was never so happy in medicine as on the days when the computers crashed. Suddenly I was no longer under the baleful cyclops eye of the computer screen, and I found I could communicate with my patient without the intrusion of a malevolent third party. So Log Off! You can have the satisfaction of knowing that the cyber moguls of the great multinational conglomerates won’t like it.
I’m beginning to think the Luddites were right.