Page 64 - JSOM Spring 2025

had to move the littered patient and hundreds of pounds of Language barriers might exacerbate communication issues in
equipment with one fewer team member, adding to the time any circumstance, but certainly in ones where people feel the
they were exposed to threats. intensity of time-sensitive concerns, such as trauma care.

The miscommunication resulted from a lack of clear expecta- Further, even when language is the same among providers and
tions expressed by the senior PJ and a lack of understanding responders, the receiving medical provider needs to reassess
by the junior PJ. The confusion could have been mitigated by the patient and interventions when accepting a new patient
closed-loop communication and clear expectations for the ju- from a provider (though in this case, this should not be con-
nior team member’s tasks during handoff at the hospital. Ad- sidered an unavoidable error because it was part of a mass ca-
ditionally, the inclusion of established verbal/hand signals used sualty response). Standardizing reassessment when accepting
during quick drop-offs (especially since, on some occasions, a patients will mitigate medical errors from miscommunication
PJ will be expected to accompany a casualty into the trauma on handoff.
bay to continue rendering care) could be used to prevent such
an event from occurring. Case 4
A CSAR team responded to a market bombing, picked up a
It is noted that the miscommunication in Case 2 did not im- small child with severe injuries, and brought him on the heli-
pact casualty care; instead, it indicated confusion within the copter to transport him to a host national hospital. Three PJs
team that impacted an operator’s availability during combat were on the helicopter, and two participated in the child’s care.
operations, which had the potential to impact both team secu- One of the PJs drew up 50mg of ketamine in a syringe. He was
rity and available care for additional casualties. not able to give the injection due to his location relative to the
casualty, so he yelled to a fellow PJ that there was 50mg of ket-
Case 3 amine in the syringe and to give 10mg. The second PJ thought
Several medics were dispatched by helicopter to respond to a he had been told to inject the syringe of ketamine. The second
125-person mass casualty event due to a bombing at a church. PJ then injected the whole syringe.
The medics flew to a nearby field hospital to help triage and
evacuate casualties. Fortunately, the child did not experience any adverse effects. In
the debrief, the second PJ felt terrible, and both PJs noted that
Upon arrival, the lead medic was directed to the military phy- they could not hear each other and did not use closed-loop
sician in charge of the small facility. The medic introduced communication.
himself and inquired about which patients were the most criti-
cal. The lead physician had an accent that the medic struggled Discussion
to understand. The physician stood over a fully exposed and
intubated patient and said, “he is expectant.” Although the Effective communication is essential to mission success, partic-
medic did not think the casualty was expectant, he deferred ularly in the stressful, chaotic, and dynamic combat environ-
to the lead physician. He began to survey the room for other ment. This review illustrates four cases of miscommunication
casualties needing immediate care. in the MPE. There were two cases of medication misadminis-
tration (one also included handoff miscommunications), one
After confirming that the other casualties were stable, the lead of a triage error during a mass casualty incident, and one of
medic returned to the lead physician and the intubated patient. an operational miscommunication error during a medevac
Further evaluation revealed an unconscious, intubated man mission. It is important to understand the nature of these
oozing blood from multiple wounds and lying fully exposed. miscommunications, common problems that constitute mis-
The patient was on a ventilator with an IV in place but no communication, and critical factors that constitute good com-
other interventions. munication: what should be said, how it should be said, and
when it should be said.
The medic asked the doctor again, “What is going on with this
patient?” The lead physician replied, “We are expecting him,” Communication failure has been cited as a primary contribu-
and gestured to the patient. The medic re-engaged with the tor to many mishaps and accidents in many high-risk indus-
lead physician, who was not a native English speaker, speak- tries 10,11 and clinical medicine. 12,13 There are numerous types
ing more slowly and precisely. This approach helped the medic of communication errors, but they frequently include unclear
successfully convey his concern about the casualty. The medic instructions, inadequate handoffs, and assumptions regarding
and lead physician then agreed that the patient should be cat- communication content. Other factors highlighted in the ci-
egorized as “immediate,” which indicated his critical need for vilian literature include multitasking during communication,
immediate intervention. The casualty was treated with pres- overworked staff, interruption during drug preparation, and
sure dressings, transfused with whole blood, packaged, and lack of continuity. It is important to understand that ad-
3,7
transported to a higher level of care, where he was reportedly ditional factors hamper communication in the MPE: enemy
doing well two weeks after this mission. threat, extreme heat and cold, smoke and fire, low/no light,
noise and vibration in aircraft, fatigue, and lack of prior coor-
This miscommunication in Case Three might have been mit- dination among different levels of care at the point of injury. 14
igated by established inter-agency coordination, standardiza-
tion of practices and terminology, and enhanced planning for Structure is the cornerstone of good communication in high-
mass casualty responses prior to the events that unfolded that risk operations. During emergencies, when time pressure ex-
day. The known vulnerability that humans have toward mis- ists and the cognitive load on individual participants is high,
15
communication must be factored into procedures for situations being explicit is critical. In the civilian world, experts in com-
where sympathetic arousal will predictably be heightened. munication and Crew Resource Management refer to the

62 | JSOM Volume 25, Edition 1 / Spring 2025