Systemic aphasia

I thought I would take a break from world politics and return to topics closer to home. The effects of stroke on a person’s ability to interact with the world, patient safety, and organisational effectiveness.

A grand aspiration, eh?

I mooted this idea first on Tuesday’s rehabilitation ward round then somewhat inarticulately in a meeting with colleagues on Thursday.

My impression was that those on my ward understood me better than the others; let’s give it a go.

Most readers will be familiar with the basics of neuroanatomy.

Specifically, the way in which one side of the brain, in most people, influences the movement on the opposite side.

My left cerebral hemisphere contains the neurones that control the movement of my right hand and vice versa. We call this a contralateral organization, contra meaning opposite and lateral, side. All of this relates to the crossing-over of neurones in the spinal cord and aspects of physiology that are pushing the limits of my knowledge (some areas of the brain do not ‘cross over’ (decussate) – we call these ipsilateral (same side), for example, the ability to sense the position of your limb in space (proprioception) (OK – these cross twice, the result is the same!)*.

I am getting off track.

When a person experiences a stroke, that is, a bleed or a clot to one side of the brain, the characteristic symptoms are experienced on the opposite side; a clot to the right will render the left arm or leg weak, for example.

The brain is divided into right and left hemispheres, with the right classically influencing aspects of behavior such as mood, humor and personality, (sometimes called non-dominant) and the left, speech, language, and numeracy (the dominant hemisphere).

Consequently, a stroke on the left side of the brain usually results in weakness of the right side of the body and impairment to speech, for example, aphasia which is an inability to express or understand language.

This is a deep topic that I will not detail further– if you are interested, you can read Oliver Sack’s classic, The Man Who Mistook His Wife for a Hat.

My aspiration is to explain that for everyone there is a left and a right side of the brain, the two, in health work in a coordinated fashion and in disease, particularly following a stroke (also in other conditions such as Multiple Sclerosis or Parkinson’s disease), can fracture to create a split.

What does this have to do with organizations and patient safety?

Well, my sense is that for a system to function optimally, each component should communicate seamlessly. There should, for example, be flow of information between and within departments, teams, and groups of staff.

Remember 9/11?

That was a classic example of a fracturing of communication between the CIA and the FBI; one branch of the government knew about and were monitoring guys who were learning to fly but not land planes and another knew an attack on mainland USA was imminent.

I suspect (and I apologize as I had intended to not mention Israel today), when the inquiry happens, there will have been people within the Israeli security system who knew something was happening on 10/7 (i.e. the young observers) and the higher-ups who were disconnected, enjoying their foolhardy Simchat Torah.

And here, I am getting to the point.

It may surprise those of you who are patients, aka everyone, that your lives are at times of critical illness supported by systems that are completely disconnected.

What the GP knows, the hospital doesn’t, what the social worker knows, the mental health team does not.

We exist within, and here is my analogy, a systemic aphasia.

Your GP may know about your allergies and the hospital may know about your allergies, there is every possibility however that they won’t have the same allergies documented. Tests you have had conducted, traumas you have experienced, symptoms suffered are frequently not accurately communicated.

The left hand doesn’t know from the right. The saying goes.

Years ago, there was a plan to establish an NHS computer system – this was one of the biggest failures in world digital integration; costing billions it resulted in nothing (OK, some tech guys became very wealthy), the nurse on your ward is still now and back in the day blind to what your practice nurse knows.

You would think it easy – just let everyone see everything.

Not so.

We have GDPR which mires everyone in bureaucratic inertia, Caldicott Safeguards and other anxieties collectively described as patient confidentiality that prevent the flow of words let alone type-written information.

I am sorry, I can’t tell you the results of your scan over the phone, for example – see Don Berwick.

How do we recover this situation?

20 years ago, there was a sense of futility for those experiencing strokes – at university, I was taught that once a neurone is lost, that is it. Gone.

We now know about neuroplasticity, the brain’s ability to grow, recover, develop, and change at any age.

Admittedly this is a very slow process that requires a patient to undertake extensive rehabilitation, there is however hope.

What about our system?

Is there ever a chance that if I am brought to the hospital unconscious one day, the doctors and nurses in A&E will be able to know as much about me as my primary care physician?

When you are discharged from hospital will your GP receive an incoherent summary hurriedly typed by a junior doctor who has never met you or will they have access and insight to the weeks, sometimes months you spend as an inpatient?

I can guarantee that most patients, following a time in hospital or after a consultation with their GP leave understanding only the rudiments; when that doctor refers you to the cardiologist or neurosurgeon, would it not be better for that specialist to have access to as much is known about you as possible (yes, even, although this might seem trivial, your name, or, what you like to be called?)

One day.

Let’s work to rehabilitate our fractured systems.

*Put that in your Brown-Séquard pipe and smoke it!