Morgantown, West Virginia, United States
Signs may be confusing and convey different meanings to various audiences
“This is no way to treat soldiers!”
The lieutenant colonel was furious as he screamed at me over the phone. After sufficient venting had occurred, I ventured a nonthreatening interjection.
“Colonel, I was not there. Tell me what happened with your soldier.”
The lieutenant colonel’s battalion has just completed their tour of duty in Iraq and were transiting through Kuwait on their way home back to the States. One of his female soldiers had been ill for about seven days with a productive cough and chest pain. Since they were close to the end of their rotation, she had decided to tough it out until they got to Kuwait before seeking medical attention. This soldier went to a troop medical clinic (TMC), which was staffed by sailors of the unit that I commanded. The lieutenant colonel further explained that his soldier was seen by two medics (Navy corpsmen, the Army has medics) and was told that her condition was not an emergency or serious and that she would have to wait until morning to see the doctor during routine morning sick call hours. The lieutenant colonel was outraged that one of his soldiers had been made to feel that she had wasted our time after having just spent one year in Iraq risking her life.
Now I understood what had happened; and more importantly, why.
“Colonel, I will investigate what occurred and call you back within two hours.”
I called that TMC officer-in-charge and gave him the soldier’s name and the date and time she had been seen. I instructed him to call me back within thirty minutes and tell me about the evaluation and treatment, but purposefully did not say why I wanted this information, as that would likely have biased the response.
Within thirty minutes, I received the requested information. The soldier had been evaluated that evening for upper respiratory symptoms. She had been afebrile, chest clear to auscultation, white blood cell count not elevated, and chest X-ray normal. She was given antibiotics and instructed to return to the TMC in the morning. The two corpsmen thought this soldier had the “Iraqi crud,” the nickname given to any respiratory symptoms in troops returning from Iraq. The next morning, the physician concurred with the assessment and treatment.
I thanked the officer-in-charge for his prompt response. I did not ask if the corpsmen had told this soldier that her condition was not an emergency and that she would have to wait until morning to see the doctor. I assumed that that was exactly what they had told her.
Every TMC had a sign posted. Left over from the unit that we had replaced, the signs gave the hours of sick call and stated that emergencies would be seen at any time. I was fine with those two statements. However, the signs also added the statement that an emergency was a threat to life, limb, or sight. I did not feel comfortable with that phrase, although I was not sure why. I had told both the Director of Outpatient Clinics and all TMCs officers-in-charge that the definition of an emergency should be removed. They argued that if we removed that phrase, troops would just show up at the TMCs any time they pleased. Since I could not articulate a good counterargument, I relented and allowed the signs to remain unchanged.
The lieutenant colonel had just given me the counterargument. Those signs were not altering the behavior of troops showing up at the TMCs, who in fact felt that they had an urgent medical issue, but they had altered the behavior of the medical providers toward those troops. When this soldier showed up at our TMC with respiratory symptoms, she did not have a threat to life, limb, or sight. Nevertheless, she had not been turned away. In fact, she was appropriately evaluated and treated. The corpsmen had taken her symptoms seriously and acted accordingly. However, because of the sign that was posted, their good actions were undone by a poor choice of words. Because of that sign, they could not resist telling this soldier that she did not have an emergency and would have to wait until morning to see the physician. Without the sign, I suspect the corpsmen would have just instructed her to return in the morning so that her symptoms and response to treatment could be monitored.
I called my Director of Outpatient Clinics and ordered her to immediately remove the phrase defining an emergency from every TMC sign.
I then called the lieutenant colonel. I could explain to him that his soldier had been appropriately evaluated and treated, or I could just apologize. I took the latter approach. Experience had taught me that explanation and justification would just be taken by the lieutenant colonel as an attempt to whitewash the entire incident. Moreover, the lieutenant colonel had enlightened me and provided me with valuable insight.
“Colonel, I investigated your complaint and have taken actions to ensure that there will be no repetition of what occurred with your soldier at my TMCs. I sincerely apologize to you and your soldier. We are here to serve you and appreciate your service. Thank you for bringing this matter to my attention.”
I could sense that this was not the response that the lieutenant colonel had anticipated. He seemed to be at a loss for words.
“Thank you, sir,” was all that he managed to say.
Signs are powerful and useful communication tools. However, they are often confusing and may mean something different to various audiences. Signs in medicine not only impact and influence patients; they also impact and influence the behavior of the providers who practice under those signs. Signs that suggest rules may transform providers into enforcers, which has the potential to disrupt the patient/provider alliance needed for good medical care.
JACK RIGGS, MD, is Professor of Neurology at West Virginia University. He spent twenty-nine years in the Navy Reserve before retiring as a Navy captain. He served almost one year as commanding officer of a combat support hospital in the Middle East.