Communication Is Everything

Part of the Internal Relief Team to Honduras 2013
Dr. Whitten, on the right, in San Pedro Sula, Honduras.

Good perioperative communication is essential for patient and provider safety. It’s difficult under the best of times, even among long standing teams. It’s especially challenging for volunteer medical providers who may never have met before. This scenario can also happen in your home hospital. Everyone has a first day working in a new hospital, or in remote locations like MRI or the cath lab. The challenge is for providers to use good perioperative communication skills to transform from strangers into a team performing high quality care. While the focus here is volunteer missions, apply the principals to everyone and everywhere you communicate.

Volunteer Missions: Challenges in Perioperative Communication

Perioperative communication during volunteer medical missions is seriously hampered by

  • lack of knowledge about fellow providers and their skill sets
  • personal attitudes and biases
  • distractions/obstacles at the site
  • the language barrier
  • cultural differences
  • problems with informed consent

Learn About Your Team

Good perioperative communication is challenging at the best of times. Working in the developing world makes it much more difficult. Most of us meet for the first time at the airport, or when we arrive at the site. We must learn to deal with our unique personalities, behaviors, and history in the space of hours before we start performing serious medical care in a difficult environment. We initially don’t know each others skill sets, comfort levels, or even emotional triggers. If you are new to medical practice or to volunteer work, you may not yet know your own.

Turn Your Group Into a Team

How do we take strangers and quickly transform them into a cohesive, well-functioning team in a difficult environment?

Be Polite

  • Learn about each other as a person. Learn each others names, find out background, and discover a little about strengths and weaknesses. We learn a lot about our own strengths and weaknesses in the process.
  • Be polite at all times, no matter what is going on. Being polite and kind to people is not negotiable, at home or abroad.
  • Treat people with respect means valuing each others point of views and being open to being wrong. It means accepting people as they are.
  • Listen deeply and with understanding in order to hear the real meaning behind words. Listen for core values. For instance, does that person value patient safety?, family?, honesty?, faith and belief?, healthy work/life balance?. After all, understanding core values helps you to better communicate with that person.
  • Realize that dysfunctional behavior may actually represent a poor compensatory mechanism for dealing with fatigue, stress and anxiety. Think of team roles from your colleague’s emotional perspective. For example:
    • a surgeon takes a patient apart and reassembles him,
    • an anesthesia provider induces controlled coma then revives the patient,
    • a nurse worries about potential complications while caring for a preop or recovering patient.
  • Give everyone the benefit of the doubt.

Be Clear

  • Be clear in all your instructions and comments. In other words, don’t be subtle.
  • Repeat instructions to ensure you heard them correctly before executing them.
  • Be Flexible. Whatever can go wrong will eventually go wrong. In the developing world things like power failures and complications must be solved without the benefit of all of our more modern treatments.
  • Be calm: Not everyone deals with such stresses as well as others. Therefore, if you project calm confidence, everyone around you will follow your lead.
  • Don’t let fear keep you from transmitting vital information. Don’t be the one to let the pilot crash the plane because you were afraid to tell her that she was about to run  into the mountain

Respect Your Foreign Team Members

Case #1

I partnered with a very talented Vietnamese anesthesiologist in a very poor hospital during a 1990s plastic surgery mission in Vietnam . She was essentially able to do everything with nothing, including intubating emergency patients digitally when she didn’t have a laryngoscope. Unfortunately, the salary that she received was not enough to support her family and she had to give piano lessons to put food on the table. Her hospital was unable to hire intensivists, and so she volunteered part of her free time each week to help cover the ICU.

Volunteers are partners with the foreign medical providers, therefore, perioperative communication needs to incorporate respect for those providers. Volunteers must recognize that medical care in the developing world is sometimes primitive because of lack of money, equipment, supplies, and training, and not because the local medical personnel are primitive. I do not envy the psychological pain they must experience because they lack treatments common in other countries. We would do well to emulate the dedication of the local medical personnel who practice despite difficulties, hardships, and often low salary .

Lack of knowledge, of course, does occur leading to the opportunity to teach. For example, some of our Honduran doctors were telling their patients to avoid looking at a computer screen for at least two weeks following a general anesthetic because it could cause blindness. However, teach kindly. After all, no one appreciates the implication that they are ignorant. 

Distractions Cause Failure in Perioperative Communication

Photo of Dr. Whitten giving anesthesia during a plastic surgery mission in Mexico. A volunteer mission showing austere conditions
Distractions during developing world volunteer missions include unfamiliar equipment, and language barriers with foreign teammates

The medications, equipment, monitors and safeguards we take for granted, and indeed cannot envision being without, are often not there. I have practiced without reliable suction or oxygen sources, the lack of EKG and pulse oximetry, and the need to manually ventilate patient in the recovery room postoperative period. That can create a lot of stress and anxiety that interferes with communication and problem solving. Distractions abound, including but not limited to:

  • Noise: Portable suction, air conditioning units (if you’re lucky enough to have them), torrential rain on a tin roof, multiple teams conversing in the same OR when more than one OR table is present can all make it hard to hear
  • Fatigue from long hours of work and jet lag
  • Exposure to waste anesthetic gases, which may not be scavenged
  • Hunger: Many hospitals are poor and food may be in short supply
  • Cultural differences: unfamiliar dress, food, decorations
  • Illness due to unfamiliar food or local infections

In such environments, extra effort to communicate is essential. Make sure instructions are clear. Repeat instructions for clarity. If you see something, say something. Watch each others backs: you are protecting both your patient, your fellow providers, and yourself. For further discussion of avoiding mishaps during volunteer anesthesia in the developing world see:

Language and Cultural Barriers

Photo from Volunteer surgery mission to Vietnam showing patients, parents and interviewers.

Case #2

I was performing preop screening in Kenya early in my volunteer experiences. My translator was fluent in Swahili and English and conversant in a third language Luo. She was translating for a mother of a 3 year old who only spoke Luo. I asked if the child had any heart problems. A long and involved conversation ensued between the mother and the translator. Two minutes passed and I was convinced that this child must have significant medical history. My translator stopped talking, turned to me with a big smile, and said “She says that she has been married for 5 years.” I suddenly realized that we would have to rely more on physical exam and a lot less on history.

Language Barrier:

You may not speak the same language as your patient, or many of the the local nurses and doctors. You also may not speak the same native language as some of your international volunteer team members. Try to have adequate translation available.

Out of frustration, people often speak faster and louder, an ineffective method to make themselves be understood. Instead, speak slowly and distinctly, separating words with pauses. Problems arising from the language barrier include:

  • missing key parts of a medical history
  • being unable to ask for help quickly
  • helpers failing to perform urgent actions, especially in emergency settings
  • failing to understand the advice the local providers are giving you
  • having your patient or staff misunderstand your instructions

I have often worked with recovery room nurses who are inexperienced in airway management. They were reassigned to the recovery room to help out with the increased patient load associated with the volunteer mission. Think about using visual aides when language is a barrier. I bring simple to understand printouts of illustrations from my books and blog to teach opening the airway with less need for words. If you find them helpful, please feel free to do the same.

Informed Consent

Case #4

On a plastic surgery trip to China, one surgeon prepared to repair a cleft lip on a toddler. He noticed that the boy also had large ear skin tags. He decided to remove those tags without consulting the parents as a surprise gift. However, the surgeon didn’t know that the boy’s village considered those ear tags a sign that the child was blessed. The villagers provided the special boy and his poor family with additional food. They were village VIPs. Removal of the ear tags caused the family’s loss of this support, as well as lowered the family’s standing in the community.

Ear tag in a toddler.
Ear tag in a toddler

Language barrier and informed consent is a major problem, both in home country and abroad. Providers from more advanced countries must often take care of immigrants and refugees, some of whom may not speak the native language of their adopted country well. These immigrants will carry with them the cultural history and beliefs of their native countries. Consider how you would feel if you needed surgery and could not speak to or understand your surgeon, anesthesia provider or nurse. All perioperative communication must take into account that predictable unease.

Pre-screening time during volunteer missions is more limited than even surgery center work back home. There will be a strong temptation to skip informed consent. However, patients need to agree to the procedure and the risks. We should never presume that we know what’s “right” for the patient. Cover the basic risks of infection, injury, allergy, and death, even if you must do it quickly. To skip informed consent means that you are denying the patient their right to control their own health care decisions.

Foreign Partners Don’t Want to Hurt Your Feelings

Many foreign providers really don’t want to say “no” to you, the visiting “expert”. They will often go out of their way to subtly tell you about some problem with your plans, while avoiding directly telling you why it won’t work. If you don’t pick up on the real message, then you can find out the hard way that your oxygen tank is running low.

Gender Issues

Not every country views male and female rights as equal. Dress codes for women providers often require skirts and dresses rather than slacks. Hair covering may be required. Some countries require women to be examined and cared for only by women. These differences must be recognized before the trip starts and accommodations made to allow any female (or male) providers to function optimally and safely.

Local Beliefs and Folk Medicine

Case #3

While in Kenya in 1987, a big local news event was a shootout between two villages that resulted in multiple casualties to the emergency room. One woman, claiming to be a witch, had sold bullet repellent to the men from the first village. That act encouraged Village 1 to attack the men from Village 2. Needless to say, the repellent did not work and both sides were searching for this woman for punishment.

We all care for patients that may have beliefs that interfere with their compliance with care. Children with cleft lips and palates may be kept hidden from attending school because they are viewed as cursed. Areas of Nigeria as recently as 2021 reported killing twins, triplets, and people with albinism. Patients may be fearful of vaccines.

Even minor beliefs can have major consequences. Mexican mothers on one mission, convinced surgery would cause pneumonia, wrapped their toddlers in wool blankets in a 90 degree recovery room, producing mass iatrogenic hyperthermia with temps as high as 104F in 5 children who had been given atropine premeds. Vietnamese mothers fed preop oatmeal to their babies to strengthen them for surgery, but kept it secret from the doctors who had told them to keep the children NPO. Several near miss aspirations occurred.

You must use sensitive perioperative communication skills to deal with folk medicine and popular belief. Be respectful as you share knowledge and encourage patient compliance. Otherwise your patients will ignore your instruction, and possibly not tell you the truth about their condition.

TeamSTEPPS and Critical Events

Perioperative communication is key for preventing and managing critical events. A shared mental model is an important part of TeamSTEPPS, or Team Strategies & Tools to Enhance Performance and Patient Safety. This approach to communication enables the creation of well-coordinated, highly effective teams. A complete review of TeamSTEPPS principles is too complicated to include here, but the key skill sets are improving communication, leadership, situation monitoring, and mutual support. Critical event training increasingly emphasizes practicing these skills on a daily basis so they are second nature in an emergency.

Agency for Healthcare Research and Quality. Pocket guide: TeamSTEPPS.

Good perioperative communication takes hard work. Use principles of good communication everywhere, including your workplace, your home and your home town.

May The Force Be With You

Christine E Whitten MD, author:
Anyone Can Intubate: A Step By Step Guide
Pediatric Airway Management: A Step By Step Guide

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon
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