A weekly newsletter on high-stakes communication — drawn from 27 years in operating theatres, military medicine, and hospital leadership. One story. One pattern. One thing you'll use.
Each piece below began as a newsletter issue — and earned a permanent home here.
The shoulder had refused to cooperate in the emergency department.
Forty minutes of manipulation. A young man in severe pain. An orthopaedic surgeon who knew when to stop and regroup.
We moved him to the operation room.
I induced anaesthesia. Midazolam first — to take the edge off. Fentanyl for the pain. Propofol to put him under. Textbook sequence.
The moment he was asleep, the surgeon moved in.
The muscles didn't cooperate either.
"Can you give a relaxant?"
I had already planned for this. Succinylcholine 75mg. Standard. Obvious — to me.
"Sure," I said. And I turned to my resident.
Blank look.
Not the look of someone reaching for a drug. The look of someone who had never been told this was part of the plan. The drug wasn't drawn up. Wasn't even in the room.
The case stalled. We deepened anaesthesia. Someone ran for the drug. The surgeon waited. The patient — thankfully — never knew.
I had a plan. It lived entirely in my head. I had never spoken it aloud. My resident had never heard it. And I had never asked him to tell me what he understood our plan to be.
The broadcast didn't happen. The verification certainly didn't.
"Everyone ready?" would have produced three nods in that room. And we still would have hit the same wall. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
The Three-Part Verification Loop
Most teams stop at step one.
Broadcast — make the information available. "Here's the plan for this case."
Confirm reception — ensure it was heard. "Ravi, did you get that?"
Verify understanding — check that what was heard matches what was meant. "Tell me what you're preparing."
That third step is where most teams never go. It feels slow. It feels like distrust. It isn't either.
It's the difference between assuming alignment and creating it.
If I had said — "We'll likely need Succinylcholine. Make sure it's drawn up and ready" — and then asked my resident to repeat that back — the drug would have been in the syringe before the surgeon touched the patient. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
This is C — the second element of the SCRIPTED framework.
SCRIPTED is a system for communication under pressure. Each letter is a distinct strategy. C stands for Confirmation — the principle that communication is not complete until understanding has been verified, not merely assumed.
Last week introduced S — Structured Formats. SBAR for handovers. Callouts for shared awareness. Read-backs to close the loop. Templates that hold the team together when the brain is maxed out.
S ensures the right information is spoken in the right structure.
C ensures it was actually received.
A structured format without confirmation is a broadcast into silence. You've said the right thing. You don't yet know if anyone heard it correctly.
The resident wasn't wrong to not anticipate it. He was junior. Anticipation comes with pattern recognition. Pattern recognition comes with experience. He didn't have it yet.
That's precisely why the plan needed to be spoken aloud. And confirmed.
Experience in the leader cannot substitute for communication to the team.