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A Communication Breakdown That May Have Cost a Heart Patient His Life

By Shane Elmore, RN

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A crazy thing happened at a restaurant here in my home town. I was having lunch with a friend when a well known man in our community walked through the door. I wouldn’t really consider this man a friend, but more of an acquaintance. He’s one of those guys that we would all like to get to know a little better, but life happens. He runs his own successful Heating and Air Conditioning business and has done so for many years now. From what I know of him, he’s a great guy.

When he was seated, I excused myself from my company for a moment to walk over and say hello … it had been quite sometime since I had spoken with Ricky and I wanted to make more of an effort than just waving at him. It’s one of those things where you see him all the time on Facebook but it’s been well over a year since you've spoken in person.  

The first question he asked me went something like this: "It looks like you’ve been traveling a lot these days from what I see on Facebook … what are you doing now?" I love what I do and I never shy away from a conversation to tell anyone who ask about how Pulsara is changing the world. I usually start off the conversation the same way; I can’t assume that anyone that hasn’t worked in a hospital really understands just how bad communication is.

So I say "Ricky, let's just say that sitting right here in this restaurant you start clutching your chest … that fried food has finally caught up with you and you’re having the big one (his smile tells me that he understands the Sanford & Son reference). After I call 911 and the ambulance shows up, it’s really important that EMS shares their findings with the hospital long before they arrive. This is especially true when you are having a particular heart attack called a STEMI."

I explain how the heart is like a pump and a STEMI is when you have a clot in the fuel line that feeds the pump. He nods his head to let me know that he follows what I’m saying. "The reason they need to share this information is due to the fact that the hospital isn’t always prepared to treat a STEMI or Stroke patient. Sure they know that one could walk in at anytime, but in order to fix your heart they have to have a team of people in the Cath Lab and that takes time … and when your fuel line is clotted off, time isn’t your friend."

This is the point in the conversation where things took an unexpected turn. This is where I usually get on my soap box about how in reality hospitals don’t communicate like they do in the movies. I started to explain just how poor the communication is when he spoke up: "Boy do I know how bad communication is. I live in a small enough town where I would have known if he had been sick or have had a major surgery. If nothing else I would have read it on Facebook. The story he told me I will never forget.

He said “A couple of months back I was in the middle of a job and my phone was ringing. I couldn't get to it so I just left it to voicemail. After I finished the job about an hour later, I checked my voicemail and I will never forget what I heard: The message said 'Dr. Salazar we just called to let you know that the heart has arrived and the team is ready for you to perform the surgery. Please give us a call back to let us know that you’re on your way.'"

Ricky told me that he went into a panic and he tried calling the number back and it went straight to the main hospital number. I’m sure he could tell by the look on my face that I understood the gravity of what he was telling me. When I asked him what happened, he just looked at me as he took a sip of his coffee. "I don’t know. I was never able to get someone from surgery on the phone. I’ve always wondered if the surgeon got the message … if that patient got their heart. I could have shown up, but I’m a heating and air conditioning man, not a heart surgeon."

I think it goes without saying that Ricky understands the challenges we as caregivers are up against. At Pulsara we are making a difference every day for patients we will never meet. The days of pagers and fax machines are no more. We are too connected in every other aspect of our lives, so why aren't we connecting care team members when the stakes are the highest? It is because we at Pulsara never want this to happen to another patient that we really take to heart our company purpose: To improve the lives of patients and caregivers through innovative communication.   

 

ARTICLE CATEGORIES: Stroke, STEMI, EMS, Trauma, Healthcare
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Shane Elmore, RN

Shane Elmore, RN

Shane is Pulsara's Vice President of Clinical Innovation, and is certified in CCRN, CEN, and CFRN. Shane is a former Chest Pain Coordinator at Trinity Mother Frances Health System.

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