37. Accidents, mistakes & chance discoveries

Key words/phrases: Serendipitous occurrences/outcomes, Frank Epperson & Popsicles, Alexander Fleming & Penicillin, Dr Mason Sones of Cleveland, Ohio & coronary catheterisation, disruptive behaviour in a psychiatric ward, Albert Einstein.

No.37

I like words. Do you ? I like the sound of them, their meanings and their origins but in particular the word serendipity has become a favourite of mine. A serendipitous finding is "an unsought and unexpected outcome of a positive nature."

It’s strange isn’t it how sometimes an individual can be actively looking for something quite specific but ends up finding something different yet useful, whilst in another situation a person who isn’t necessarily seeking to discover anything finds that he or she does !

Frank Epperson of San Francisco, for example, was eleven years old when he accidentally created what we now call the ice lolly. One day he mixed himself a drink of water and soda water powder - a popular drink in 1905 and then left it haphazardly on his back porch with the stirring stick still standing in it. When the overnight temperature dropped the mixture froze and much to his amusement Frank found that he had a stick of frozen soda water to show his friends at school the following morning. Eighteen years later, he started producing what he called 'Epsicles' in different fruit flavours and although the name never really caught on over three million 'Popsicles' are now sold in America every year.

If we think about penicillin, Alexander Fleming wasn’t actively "working" when he felt compelled to show a visitor what he was doing in his laboratory. He simply noticed that one of his petri dishes - which he in the process of disposing of - had become contaminated with a mould. On closer examination he found that the invader that had settled on the surface of his culture plate while he had been on holiday was killing off the the staphylococcal micro-organisms. No-one could have blamed his other colleagues for labelling him ‘lazy’ because of the way that he regularly neglected to clear up after himself and yet three years later two other researchers were able to create a stable form of this naturally-occurring fungus to give the world what was to become its first antibiotic.

The first case of coronary catheterisation was serendipitous too. In 1957 a paediatric cardiologist at The Cleveland Clinic, Ohio was attempting to inject some dye into the heart a young patient with valvular disease when he discovered that the cardiac catheter had accidentally entered the child’s right coronary artery and that 30ccs of contrast dye had been released.

Thus Dr. Mason Sones accidentally discovered that the coronary arteries could tolerate contrast dye. Soon afterwards he went on to perfect new techniques for producing high quality diagnostic images of the coronary arteries using specially designed catheters. Thus this accident made accurate diagnosis of coronary artery disease possible for the first time and ultimately set the stage for such future interventions as bypass surgery and coronary angioplasty.

So what I am trying to flag-up here is that although I accept that in general terms we do need clear aims and objectives to help us to structure the work that we do in our hospitals and the efforts we make in our communities, nevertheless chance happenings and accidents can still sometimes produce unexpected and positive results.

I wonder if anyone reading this can recall a mistake that they or someone else made at Joyce Green Hospital which nevertheless had a positive outcome ? Either a practical mistake or a misjudgement of some sort but nonetheless one which had a useful outcome for a patient, a colleague, a relative or someone else ?

Whilst working in a psychiatric hospital once (unconnected with JGH) I can remember taking a very belligerent young male patient by the scruff of his neck and putting him out of the ward and on to the main hospital corridor when I was on duty alone one night.

This young man was disrupting the whole ward and although he was quite capable of controlling his behaviour on this occasion he was really letting rip. So almost intuitively I decided to deprive him of his audience and to exclude him from his temporary ‘substitute home’. Talking calmly to him wasn’t working and he was refusing to take his medication and so because he was menacing other patients and being destructive I decided to do something out of the ordinary both for his sake and for theirs.

And do you know what ? Although this was an unusual and completely nursing unplanned intervention it worked …. and within a few minutes he was knocking on the locked ward-entrance door apologising and asking if he come back on to the ward.

As Albert Einstein once said: “Not everything that can be counted counts and not everything that counts can be counted.”