Anatomy of dialogue in out-of-hospital cardiac arrest resuscitation
Marzuki, Ernisa Binti
Research on medical teams constantly recognise the crucial value of communication. Studies on various medical teams, such as surgery and trauma, provide evidence for how communication either affects or is affected by a range of outcomes and variables. Nevertheless, much of this work has focused on in-hospital communication. Less is known about the patterns of communication amongst medical practitioners in high-stakes emergency care outside of the hospital. This thesis presents an investigation of dialogue during pre-hospital resuscitations when paramedics are responding to out-of-hospital cardiac arrest (OHCA). A bespoke dialogue annotation system, called the Dialogue Annotation for Resuscitation coding scheme (DARe), is developed for this purpose. DARe is used to annotate four simulated and 40 real-life OHCA resuscitation attempts by paramedics who are based in Edinburgh, Scotland. We examine (1) the distributions of communicative functions and subject matters (threads); (2) specific statements used by team members to align themselves; (3) the prevalence and forms of mitigated directives; (4) the verbal manners of planning; (5) the occurrence of closed-loop communication and other structures of verbal communication loops; and (6) the prevalence of socioemotionally-related utterances. For the real-life resuscitation dialogues, the study additionally investigates (7) the correlations between the distributions of the dialogue patterns with the assessed performance of resuscitation team leaders and with the time taken to successfully deploy a mechanical chest compression device (AutoPulse). Analysis for the simulation dialogues was performed from the start of simulation until the end or near the end of the procedure, whilst analysis for the real-life dialogues concentrated on the first five minutes. Despite this difference in timing, the results showed that simulated and real-life OHCA dialogues comprised similarly high frequencies of statements, directives, acceptances, and acknowledgments. Both simulated and real-life dialogues also contained sociolinguistic influences from the linguistic context that these were derived from, i.e. Scottish English. In considering the threads across both settings, the largest proportion of threads revolved around planning and execution of tasks, followed by threads on patient history and related instrument/equipment. Dialogues during real-life OHCA resuscitations differed from the simulated resuscitations in the additional presence of two communicative techniques, namely Alerters (used to attract hearer’s attention) and Affective performatives (used to convey affective or socioemotional statements). Additionally, real-life resuscitation dialogues contained a larger proportion of threads pertaining to patient positioning due to the use of the AutoPulse. Resuscitation team members often used a statement structure called State-awareness to align themselves with one another in terms of their current state or task. Directives were frequently mitigated, with strategies ranging from simple use of softeners (e.g. please) to less straightforward directive structures (e.g. suggestion). Plans were verbalised in temporal clusters, i.e. distinguishable in terms of the immediacy of the task to be performed. Few verbal affective behaviours (e.g. humour, gratitude, compliments) were observed. Team members also used very few exchanges that resembled the standard, three-level closed-loop communication structure typically required from professionals in other high-stakes dialogue environments. Correlation analyses revealed that the frequencies of both the communicative functions and threads were associated with the performance scores of resuscitation team leaders. Teams led by higher rated leaders (the ideal score group) showed higher proportions of Alerters, Affective performatives, State-awareness, and Plan of action in their dialogues compared to teams led by lower rated leaders (the low score group). There were also variations in the concentrations of chest compressions, patient history, and rhythm threads in the two groups, indicating that both discussed the same threads but at different junctures of the procedure. Meanwhile, the time taken to deploy the AutoPulse was positively correlated with the communicative function Acknowledge and the threads Patient history and Movement other than patient, and negatively correlated with the communicative function Open-option and the threads Ventilation and Airway access. Based on these results, several potential measures for optimising OHCA resuscitation are proposed: the use of sewn-on name badges for paramedics; shorter time dedicated for the extraction of patient history; verbal reports of vital points throughout the procedure; the use of non or less mitigated directives; and standardisation of resuscitation phrases. Each suggestion is also discussed in terms of anticipated challenges and possible solutions. The results presented in this thesis provide grounds for further research on the features of pre-hospital resuscitation dialogues. DARe has been demonstrated to be useful in discriminating linguistic patterns, suggesting that dialogue annotation analysis can be utilised to further investigate this area and ultimately contribute to resuscitation performance.