This month’s AIRS case reports both deal with communication. As we’ve done before, we presented the cases this time in a format that we’ve borrowed from NASA’s CALLBACK publication, which discusses events that have been entered into the Aviation Safety Reporting System. We’ll let you “interact” with the information given in two events that have been reported to AIRS. In “The First Half of the Story,” you will find report excerpts describing the management of a patient’s airway up to a point where the anesthesia team must decide what to do next. You can then think about what you would do in a similar situation. How might you best resolve the problem we’ve presented? You’ll find out what the actual health care team did in “The Rest of the Story.”

“Resident physicians who work in training institutions often debate whether they should ‘bother’ the responsible attending physician when a patient’s clinical status changes. In this case, the attending wasn’t aware that a potentially life-threatening event was occurring because a junior resident did not recognize the gravity of the situation. This lack of communication delayed care and ultimately required the intervention of a rapid response team.”

Case 1

An appendectomy was scheduled at one of the hospitals that our group covers with an anesthesiologist who takes home call. The anesthesiologist did not respond to repeated phone calls. We later found out that the anesthesiologist had accidentally placed his telephone on silent mode. What would you do?

Case 2

A 12-year-old girl underwent an exploratory laparotomy for an acute abdomen. The surgery went well, and the patient was transferred to a floor bed. Shortly after she arrived, the nurse became concerned about her vital signs. The nurse sent a message to the resident who was caring for the patient. The resident did not seem concerned and said that they would come to the bedside when they got a chance. What would you do?

Case 1

An astute partner in our practice sent an Epic secure chat message urgently, which breaks through silent mode and alerted the anesthesiologist to the procedure.

Mobile telephones are ubiquitous, and it’s intuitively obvious that they can make people easier to reach. In fact, one of the first studies to show that mobile telephones improved care was published over 17 years ago (Anesth Analg 2006;102:535-41). Since that early work, instantaneous communication has moved beyond voice calls and now includes text messages, and at least one study has shown that “asynchronous” communication (i.e., text messaging) is more efficient (BMJ Innov 2021;7:68-74). Mobile telephones have also been shown to improve patients’ health! In one systematic review, interventions over a mobile device increased medication adherence and improved forced expiratory volume in one second and hemoglobin A1c percentage! (J Telemed Telecare 2017;23:693-700).

Another survey-based study found that, even as late as 2017, residents were more likely than attending physicians to use smartphones for learning and accessing information related to patient care. Personal experience and confidence affected both groups’ willingness to use their mobile telephones (Intern Med J 2017;47:291-8). That study concluded that guidelines for clinical use of mobile phones were needed. For physicians and patients to realize these benefits, however, the device has to work, and the physician has to hear it ring. Although no studies have yet been published about physicians on call whose telephone wasn’t working, it seems reasonable to assume that this is not infrequent. So how can we be certain that we’re receiving calls when we’re on call? In addition to ensuring that the telephone is not set to silent mode, most mobile devices allow specific numbers to be programmed so that they will always activate an audible tone. For example, on the Apple iPhone, one can select “Emergency Bypass” under the ring and text tones (Figure). Another safeguard is to carry a backup mode of communication, either a pager (remember those?) or a partner’s phone, for which the hospital’s number is also set to bypass silent mode.

Case 2

The patient worsened over the next two hours. A rapid response team was called, and the patient was transferred to the ICU. She was ultimately diagnosed with sepsis.

Resident physicians who work in training institutions often debate whether they should “bother” the responsible attending physician when a patient’s clinical status changes. In this case, the attending wasn’t aware that a potentially life-threatening event was occurring because a junior resident did not recognize the gravity of the situation. This lack of communication delayed care and ultimately required the intervention of a rapid response team. Although this case might have involved a surgical resident, this sequence of events can happen to anyone who works in a team care environment.

When should the responsible attending physician be called? One research group conducted a survey study and developed a “must call” list (Table) (J Surg Educ 2008;65:206-12). Although this list applies primarily to our colleagues who may work in the intensive care unit or wards, it offers a reasonable starting point to open a discussion about when team members should ask for help. Some events, such as hemodynamic instability or the need to intubate a patient undergoing a procedure under a regional anesthetic, are also applicable to clinicians who work primarily in the OR.

graphic

All members of the anesthesia care team can benefit from learning conflict management skills. One study identified specific skills that can improve care in the pediatric OR but that apply to all clinical settings: Active listening is a teachable skill that improves team dynamics and information transfer. Members of the care team should acknowledge and manage their emotions during conflicts. Collaborative problem-solving is encouraged by aligning the interests of all members of the care team (Anesth Analg 2019;129:1109-17). This case shows that it doesn’t matter how well a smartphone or paging app works if the person on the other end doesn’t get the message.