Wednesday, 26 March 2014

Somebody is Nobody: The unspecified receiver in communication

The following story is based on actual events:
It's 10pm in the Emergency Department (ED) when a stand-by call is received. A 25-year-old man has been knocked down by a car travelling at high speed. He has multiple limb and facial fractures and the paramedic is concerned about splenic injury and intra-abdominal haemorrhage as his abdomen is becoming distended.

This case requires efficient and effective teamwork and leadership. The orthopaedic and general surgeons are called to attend, as is the anaesthetist and anaesthetic assistant. The patient arrives in hypovolaemic shock. The team of 8 or so people work together to assess and begin treatment. 
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Life-threatening splenic haemorrhage is thought to be the most likely cause of his continuing deterioration and the patient receives O-ve blood on his way up to theatre. The surgeon begins his laparotomy to control the bleeding. The 3rd unit of O-ve blood is squeezed into the patient and the anaesthetic assistant is asked to contact the transfusion laboratory to ask when the cross-matched units will be available. To her surprise she is informed that the lab never received a sample and therefore they haven't even started to cross-match blood. What happened?

If we had a video-recording of the events in the ED resus bay we could look for causes of the missed blood transfusion request. Undoubtedly many factors played a part: perhaps the organisation does not have a standard operating procedure (SOP) for trauma patients, perhaps there is no checklist for making sure that all essential tests and procedures have been carried out… However, one of the factors was the following communication from the anaesthetist:
"And can someone make sure he's cross-matched for 8 units?"

Someone, Somebody, We…. 

In simulated scenarios and in the clinical environment, it is common to hear the same sort of communications:
"Can somebody call for help?"
"Could someone please check he's not allergic to anything?"
"We need a chest drain and we need to get IV access"
The common characteristic in all of these is the unspecified receiver. When a situation is stressful and dynamic, roles and tasks are not rigorously defined and workload is high then the "somebody" becomes "nobody". The danger then is that a task is not completed as illustrated in the scenario at the beginning of this post.

There are several reasons why we may use this form of communication:

  • Politeness: We don't want to seem dictatorial
  • Mental workload: It is easier to have an unspecified receiver than to maintain the situational awareness required to appreciate who could carry out a given task
  • Uncertainty: We are unsure who is capable of performing the given task and hope that those who are capable will step forward
  • Unfamiliarity: We don't know the names of the people in the team (cf. WHO checklist brief) and don't want to say "Hey, you, with the glasses! Cross-match some blood!"

How to specify the receiver

The following tips may lead to fewer unspecified receivers:

  1. Always specify the receiver. Some people argue that the receiver need only be specified in crises, however if we don't specify the receiver during low workload tasks there is a risk that we will not do so in high workload and high stress tasks.
  2. Know your team-members. If you don't know people's names, ask them or ask for a quick shout-out as to name and specialty. Have name-badges which are visible and legible.
  3. Use closed-loop communication. An unspecified receiver does not close the loop.

Further reading

St.Pierre, Hofinger, Buerschaper and Simon "Crisis Management in Acute Care Settings (2nd ed)" p235-236

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