Communication. Such a simple concept. And yet so many ways in which it can fail.
Two examples of communication failures hit the news this past week, both of which have potentially severe medical repercussions, albeit on very different scales.
The first occurred this past Saturday at a Big Ten football game. The quarterback took a hard hit, and his head slammed backwards onto the ground. When he got up, he was so shaken and off-balance that he stumbled and collapsed into his teammate. So obviously, he would be pulled from the game and given medical attention, right? Nope. The coach put him back in for another play, as the crowd booed its displeasure and indignation. No one could believe the coach would show such blatant disregard for his player’s well-being, and there are strict regulations in place regarding head injuries in sports and protecting the athletes when there is any suspicion they have suffered a concussion.
But the coach didn’t pull the player out for a neurological check because he (the coach) hadn’t seen the player’s hit, his head-slam, or his resultant signs of head injury. The coach knew the quarterback was playing on an injured ankle (which had been medically cleared for play), and when he saw him limp back to the sideline, he assumed it was an ankle issue, stuck him in for another play, then had medical personnel check his ankle, and put him in again. Thousands of people in the stadium saw what happened. Millions of people saw on TV. Everyone assumed the coaches saw. But they didn’t – they were monitoring so many different things, planning, talking to people, and assuming important information would get to them. But the information didn’t get to the right people.
The university where this occurred is taking steps to ensure such an event doesn’t happen again. For example, they’re placing medical personnel in the press box for future games and giving them direct communication lines to the coaches. Systems approaches are good. They help. I’m glad they’re putting in extra safety layers to protect their student athletes, and I hope other schools and teams follow this lead. But systems measures can only go so far. We also need individual safety layers, and I cannot overstate the importance of personal advocacy (both self-advocacy and advocacy of others).
If the quarterback had said, “Hey, Coach, I hit my head and don’t feel right,” or, if he was too dazed to speak for himself, if his teammates had told the coach about the injury and their concern, or if anyone who had seen the incident had spoken up and relayed the information to the coach, then the athlete would have been given prompt medical attention and not sent back out on the field to be head slammed again. People need to speak up. And they need to speak up to the people in authority – the decision makers – and not just grumble quietly or complain amongst themselves.
Earlier this week, the news hit that the first person in the U.S. had been diagnosed with the Ebola virus. Ebola requires close contact with someone who is symptomatic with the disease in order to spread. We have good infection control measures in U.S. hospitals. We have quick dissemination of news. We have the CDC (Centers for Disease Control and Prevention). We have state and local health departments. We have a lot of good systems in place. The patient had recently come from Liberia, where there is a current outbreak of Ebola. He developed symptoms, he went to the hospital, and he told some of the medical personnel that he had just recently returned from Liberia. And he was sent home with a prescription for antibiotics. And he continued to be symptomatic, exposing other people for days, until he returned to the hospital and received the correct diagnosis, appropriate medical care, and concomitant infection control measures.
In this case, the patient actually had communicated the important information, but it didn’t get to the correct people. A systems issue, to be sure. But more individual advocacy and strong communication would go a long way here, too.
I was not on the sidelines with the football team, and I was not in the emergency room where the patient first presented, but I have some pretty good ideas as to some of what may have been going on.
Both the sidelines of a football game and an emergency department can be bustling with action. Things are going on in different areas. Different teams (offense, defense, trauma, radiology….) and their respective coordinators (offensive and defensive coaches, head coaches, triage nurses, nurse practitioners, attending doctors, etc.) are functioning within a larger whole, trying to attain their overarching goal (winning a game, getting all the patients taken care of) while trying to maintain the well-being of each individual (the athletes, the patients). With so much going on, communication frequently suffers. And when people are nervous about speaking up, communication suffers.
Players may have been afraid to “argue” with a coach. They may have assumed the coach knew all the facts. The patient or his family or the nurse he originally spoke to may have assumed the ER doctor or Physician’s Assistant or Nurse Practitioner who discharged the patient had read the travel history and considered the possibility of an Ebola infection. Both situations just needed someone, anyone, to say to the decision maker, “Hey, wait a minute. Do you know that (I hit my head and can’t walk straight/the quarterback looks like he has a concussion/this patient was just in a country with an Ebola outbreak/I just flew in on a plane from Liberia)?”
Systems approaches. Individual back-ups. Individual care. Systems back-ups. All necessary to minimize the holes in the information sieve. Don’t skimp on the systems. But also never be afraid to plug the holes in the systems yourself.