Thursday, September 1, 2016

Cry Wolf or Wolf Cry: A Safety Culture Story

To cry wolf is to ask for help when it is not really needed. This rarely happens in medicine. Instead, perhaps far too often, the inverse is frequently true: we don’t ask for help when help is really needed.

This is the Wolf Cry Problem.

One night, I received a page while working a shift on night float, covering nearly forty adult medical patients in the hospital overnight. Beep after beep, the pagers (four of them) rattled around in my white coat pocket. Per habit, I found a phone and returned this page as fast as I could, unaware of what message I would receive on the other end of the phone call.

“Are you covering Mr. J in Room 4?” the nurse asked.

“Yes; I am,” I replied.

“He’s coughing up blood. Could you please come assess him?” stated the nurse, the sound of concern resonating in her voice.

“Yes; I’ll be right up,” I assured her.

She wasn’t crying wolf.

As I made my way to the patient’s room, I ran through potential scenarios in my head, considering the differential of consequence, preparing to think through rapidly what could be causing this bleeding.

And as I walked into the room, immediately, my first thoughts were clear: this patient is sick; this patient is bleeding actively; this patient needs a higher level of care. I called in my senior resident right away; that’s one of the first most important steps for me to take as an intern in residency training: communicate effectively with physicians higher in the hierarchy who are also responsible for caring for my patients.

My senior made his way to the room, joining me as we worked together to assess the patient and prepare for the possibilities (ordering fluids and blood for resuscitation, for example, to start).

But things evolved quickly.

At first, the patient was coughing up small amounts of bright red blood. The nurses suctioned it away. Within minutes, however, the rate of bleeding started to uptick. The senior resident recognized this shift and called the intensive care unit (ICU) attending physician, activating the highest level of care provided at the hospital.

And when the ICU physician arrived soon thereafter, the flood gates opened: the patient started hemorrhaging. The patient had esophageal varices that started bleeding. Esophageal varices are engorged veins around the esophagus; they are full of blood that backs up when blood flow through the liver slows down due to liver disease. This particular patient had a chronic hepatitis C infection in his liver; as a result, blood flowed poorly through his liver, making his liver like a leaky damn. Once esophageal varices “pop” and start bleeding actively, the horse is often already out of the barn: outcomes are poor because it is difficult to stop—to tamponade—the bleeding given the human anatomy at that location in the body.

That’s what happened in this case, unfortunately. What does this story illustrate about patient safety? A simple observation of safety culture.

During the moments between when the senior resident called the ICU attending and when the ICU attending arrived to the patient’s room, the nurses spoke amongst themselves briefly:

“What ICU attending is on tonight?” asked one nurse.

“I hope it’s not Dr. Y; he’s always such a jerk when we call,” another nurse stated.

“I think Dr. T is working tonight. He’s gruff and all, but at least he works with you and appreciates being called,” said the third nurse.

Stepping back, I reflected about this interaction. In the face of a patient bleeding out, we may cling to the ideal of aequanimitas, but that’s merely a fa├žade: we are human beings after all. Patient safety culture is grounded in teamwork; and how we relate to and work with each other on teams influences how we care for our patients. It occurred to me that we, as healthcare providers, may hesitate at times to escalate a situation to a higher level of care appropriately because we worry about how we will be treated—or mistreated—by the healthcare providers higher in the hierarchy. When we ask for help and receive disrespectful or negative reactions from higher in the hierarchy—perhaps by dismissing or minimizing our concerns—we may be prone to not call for help in the future when the help is really needed. Herein the Wolf Cry Problem arises.

Supporting safety culture is not just about being “nice” to each other (though that is nice); it’s about really trying to work with each other—even when we are fatigued and tired—to help each other as teammates with a shared purpose. We understand (and expect) that people may not act as hospitality executives when immersed in a stressful patient care case, but what this story illustrates is that we may benefit from being mindful of how the totality of our interactions with our colleagues influences their future behaviors in serious patient care situations.

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