…larger improvements in seeing should occur when people with more diverse skills, experience, and perspectives think together in a context of respectful interaction. Karl E. Weick (2002) It has become increasingly obvious that factors such as communication, teamwork, and leadership have significant roles in patient safety (Nagpal et al. 2012). Of these factors, communication is perhaps the most significant, both as a skill in itself and because effective communication is integral to the success of all other parts of the “system” (Nagpal et al. 2012). It’s the glue that binds. Indeed, it is the critical factor if healthcare teams are to deliver effective and safe care to patients. As discussed previously (see “Communication: what it is and how it fails” in Chapter 2), communication is the process by which information is passed orally or in written form from one individual to another. But communications can break down and do so in three ways: (1) information is never communicated because it is missing or incomplete; (2) during the communication process information is misunderstood or transmitted poorly (a poor method or structure is used for communication); and (3) once communicated the information is forgotten, inaccurately received, or interpreted incorrectly. In healthcare, when communication breaks down patient safety is jeopardized, a reality that has been documented in a number of clinical settings, including general medicine, emergency departments, and surgery (Brindley 2014; Greenberg et al. 2007; Lingard et al. 2004). Teamwork is the array of interconnected behaviors, cognitive processes, and attitudes that make coordinated and adaptive performance possible in complex environments such as clinical settings (Salas et al. 2008). Not surprisingly when communication breakdowns occur teamwork is less than optimal and patient safety is jeopardized (Brindley 2014; Lingard et al. 2004). Based on evidence from acute care medicine it has been claimed that inadequate teamwork (and the related topic of inadequate communication) is one of our most common reasons for preventable error (Brindley 2014). A recent set of proposals for improving diagnosis in healthcare included the facilitation of teamwork as one of eight major goals (Bunting & Groszkruger 2016). Is communication an issue in veterinary medicine? We would be naive to think otherwise. Indeed, recent reports confirm that communication breakdowns do contribute to errors in veterinary medicine (Kinnison et al. 2015; Oxtoby et al. 2015). The following cases and near miss vignette are examples of breakdowns in communication within the context of veterinary anesthesia. A 1-year-old, 18.2-kg hound-cross bitch was brought into the emergency receiving service of a referral practice. The owner’s primary concern was that the dog was pregnant and had been straining to deliver puppies over the past 48 hours. When asked about the breeding date the owner stated the dog ran free but the owner had observed her being bred approximately 2 months previously by a local dog. The only other item in the dog’s history was that she had been hit by a car 5 months previously but without any lasting effects. The emergency service clinician on duty was a surgeon who promptly took the dog to radiology for an abdominal ultrasound examination that was performed by a visiting veterinary radiologist. The ultrasound exam was difficult as the bitch was uncooperative; the ultrasound was interpreted as indicating that there was one fetus. The dog was taken to the anesthesia section for induction of anesthesia and an emergency caesarean section. When presenting the dog to the anesthesia service, the surgeon demanded that the patient be anesthetized immediately so that the puppy could be saved. The anesthetist on duty asked for more information about the patient, but was told in an abrupt manner to “quit delaying and get the dog on the table.” Undeterred by this admonition, the anesthetist proceeded to perform a quick physical examination. The dog was found to be unkempt and nervous. She became aggressive when abdominal palpation was attempted and had to be muzzled. Her heart rate was 138 beats per minute and she was panting. Mucous membranes were pink and capillary refill time was 2 seconds. Her temperature was 39.9 °C, hematocrit was 31%, total plasma solids were 5.8 g dL−1, blood urea nitrogen (Azostix) 1.8–5.4 mmol L−1, and blood glucose 3.83 mmol L−1. Under the assumption that the bitch was pregnant and so as not to depress the fetus any more than necessary, she was not premedicated. A catheter was inserted into a cephalic vein, she was administered oxygen by mask for 5 minutes, and then induced to anesthesia with propofol. The dog’s trachea was intubated and the endotracheal tube was connected to a circle circuit delivering isoflurane (1%) in oxygen (2 L min−1). When positioned in dorsal recumbency the vaporizer was increased to 2% because the dog seemed light. It was also noted that her thorax had poor compliance as it was difficult to manually ventilate her and the thoracic wall did not move to the extent expected for the size of the manually delivered tidal volumes. The position of the endotracheal tube was reassessed and because of remaining doubts as to the position of the endotracheal tube, the dog was extubated and reintubated. Despite this maneuver, the dog remained difficult to ventilate. A catheter was inserted into the dorsal pedal artery for continuously monitoring arterial blood pressure and periodic sampling of arterial blood for blood gas analysis. Because of her low plasma protein, dextran 70 was started in addition to lactated Ringer’s solution. After surgical preparation the dog was moved to the OR. Once positioned in dorsal recumbency and while breathing spontaneously, an arterial blood sample was collected for blood gas analysis; the results were: pH 7.22, PaCO2 55 mmHg, PaO2 51 mmHg, standard base excess −5.1 mEq L−1. Mean arterial blood pressure was 105 mmHg, heart rate was 120 beats per minute, SpO2 was 89%, and PE′CO2 was 39 mmHg. The surgeon made a ventral abdominal midline incision. As soon as the abdominal cavity was entered, all evidence of the dog’s ventilation ceased in that the reservoir bag stopped moving and the capnograph went to zero. Mechanical ventilation was initiated and the anesthetist asked the surgeon to check the dog’s diaphragm. The diaphragm had a rent in it with portions of the liver including the gallbladder and omentum extending through the rent into the thoracic cavity. The thoracic cavity was tapped and 100 mL of serous fluid was removed. After a median sternotomy was performed to gain better access to the thoracic cavity, an additional 2 L of fluid was removed and further exploration revealed a torsion of the right middle lung lobe. Fibrinous, purulent material floating freely in the abdomen was assumed to be the “puppy.” Because of the dog’s unstable condition under anesthesia the surgeon decided to close the chest, leaving resolution of the lung lobe torsion to a later date (performed 8 days later). Anesthesia lasted 125 minutes. The dog was recovered in an oxygen cage in the ICU where the remainder of her recovery and analgesia were managed. The dog obviously had a diaphragmatic hernia, but some elements of the case at presentation led the receiving veterinarian to make an initial diagnosis of dystocia. The owner’s history of the dog and her opinion that the dog was trying to deliver puppies, certainly set the stage for this diagnosis. There was also confirmation of this diagnosis by the radiologist, and the limited blood work provided additional, seemingly confirmatory evidence. The hematocrit was 31% and total plasma solids were 5.8 g dL−1, numbers that are expected in a bitch at term. However, the blood glucose of 3.83 mmol L−1 was low and, at the very least, suggested that the dog had an inadequate diet. For the anesthetist managing this patient, details of the history and physical examination, including the nervous and aggressive nature of the bitch and her unkempt hair coat, the latter finding suggesting she was not well cared for, all suggested that something was amiss. This was not a typical at-term patient. The anesthetist’s experience in managing anesthesia for numerous caesarean deliveries was that most bitches with dystocia are not aggressive, even during abdominal palpation. In fact, most of them presenting for emergency caesarean delivery are quite manageable, possibly because of exhaustion, dehydration, and lack of sleep. Had there been better communication between anesthesia and surgery, had they functioned as one team instead of two seemingly antagonistic teams, the patient and the client would have been much better served. Indeed, had there been better communication between the services (including radiology), and a sharing of information, observations, and findings about the bitch’s condition, a more thorough understanding of her condition may have developed. A complete blood count (CBC) probably would have indicated that this dog had an ongoing inflammatory process. However, knowing that there would be a delay in obtaining the CBC results along with concerns about the well-being of the puppy and a sense of urgency to get the dog to surgery, probably would have led both teams to relegate this blood work to the bottom of the to-do list. However, a radiograph of the abdomen, especially if it included the caudal portion of the thorax, would have been very informative. Radiographs would have ruled in or ruled out the presence of a fetus by revealing its skeletal structure, which at term would be obvious. Ultrasound, especially in an uncooperative and aggressive animal, is not necessarily diagnostic in a case such as this. None of these steps were considered and the true diagnosis only became apparent at the beginning of surgery. A diagnostic error occurred early in this case, but it was then exacerbated by breakdowns in communications. The dog’s history of having been hit by a car 5 months previously was important, but the owner was not questioned further concerning that event. No one in the veterinary team dealing with the case knew if the dog had been taken to a local veterinarian for workup and treatment after being hit by the car, or had recovered on her own at home. This historical entry about the accident was treated as an historical aside and given little importance in the overall assessment of the dog. However, opportunities to correct this initial mistake were missed due to other errors. The environment in which we work (the context) affects patient care either positively or negatively. In this case there was an ongoing tension between the surgery and anesthesia services due to a perception by the surgery service that anesthesia intentionally delayed its cases. These tensions led to poor interdisciplinary communication and teamwork and as a consequence patient care was suboptimal and the client was not well served. This case has some features in common with the polar bear case (see Case 6.1 in Chapter 6). In both cases the veterinarians became fixated on what seemed to be each patient’s primary problem, whether it was fractures or dystocia, and did so without considering other problems that were in fact present and to which a number of signs strongly pointed. In other words, a fixation bias existed. Both cases also present what could be called the “visiting professional trap.” In the case of the polar bear, the zoo veterinarian was an outsider to the referral hospital’s anesthesia and surgical team. Out of professional courtesy and in recognition of his expertise with the medical care of zoo animals, that team did not question what turned out to be an incomplete diagnosis despite many signs pointing to serious internal injuries. In this case of the pregnant bitch, the visiting professional trap was the visiting veterinary radiologist. During rounds at which this case was discussed, it was discovered that the visiting radiologist was inexperienced in ultrasonography and was visiting the practice to gain additional training in this imaging technique. On the day this patient presented for ultrasound examination the supervising ultrasonographer in charge of training the visiting radiologist, was off the clinic floor and unavailable to review the case. So what’s the lesson? Amongst colleagues—whether known or strangers—it is always acceptable to question a diagnosis and how it was arrived at. Yes, such questioning should be done in a collegial manner, but when the circumstances so indicate, thoughtful, probing questioning is appropriate. The dog had a diaphragmatic hernia, a diagnosis that ties together so many clues in the history and physical examination. It is also apparent that the uncollegial environment of this practice at that time precluded a team approach to patient management. A functional team probably would have been better able to sort through this patient’s history and physical examination so as to make a medical diagnosis as opposed to an unexpected surgical finding.
CHAPTER 7
Errors of Communication and Teamwork in Veterinary Anesthesia
Cases
Case 7.1
Initial analysis of the case
Investigation of the case
Case 7.2
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