Introduction :
Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education. Each month we publish a case and link a paper with associated questions for discussion. Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.
The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post! Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience. We look forward to hearing from you.
Title : “Sound and Fury”
The Case :
For a brief moment in the chaos, time had seemed to pause. The cacophony in the resus room was rising but through it all the quiet wail of the infant’s parents was cutting through it all as if their grief was physically squeezing Cath’s heart.
She felt the vivid tremor of her hands.
In that instant it was as if she could physically see the emotions in the room, manifesting like coloured balls of light that bounced and echoed around the bedside.
She saw her Fellow Nitin knock away the cannula tray and reach for the Intraosseous, the stress glowing a vivid red from within his chest.
She saw Harriett the social worker kneeling by the parents’ chair, shielding the team from some of the thick, black grief that poured out through their tears.
Brad and his team from ICU had walked in and gravitated straight to the ventilator. He was a wonderful man but she could feel his frustration with the team brewing. She had been friends with him long enough to know he was about to snap, and the fact she was disappointing an old colleague filled her with a yellow flush of shame.
As her panic began to overwhelm, the nursing team leader moved into Cath’s field of vision. She spoke just loud enough to be heard.
“You’ve got this. We’re here for you.”.
Cath closed her eyes and slowed her breathing.
It was time to take back control.
The Article :
Hicks, C. and Petrosoniak, A. (2018). The Human Factor. Emergency Medicine Clinics of North America, 36(1), pp.1-17.
Discussion :
Destined to become a classic paper we are pleased to feature Hicks & Petrosoniak’s newly released from Emergency Medicine Clinics of North America. While not specifically focused on simulation, ‘The Human Factor’ takes knowledge formed and refined within the simulation room and translates it back into clinical practice.
As Simulation Educators many of us have been conduits for bringing the gospel of CRM into the healthcare workplace and as such this paper provides an important deep dive into current thinking on human behaviour and training strategies to improve our performance in a crisis.
We look forward to hearing your thoughts on this paper, and in particular :
- What strategies from this paper might help Cath’s team regain control of a chaotic situation?
- How might this paper effect your educational practice and debriefing strategies in CRM?
- Will it effect your clinical practice as well?
References :
Hicks, C. and Petrosoniak, A. (2018). The Human Factor. Emergency Medicine Clinics of North America, 36(1), pp.1-17.
Hi Simulcast team – nice to see the journal club back online after the festive break! Thanks for sharing this great article – so much goodness in it, that I would need to read a few more times to absorb it all! So much relevance for us simulation educators, even though its not specifically a simulation article.
They talk of strategies of optimising management of individual, team, enviroment and systems – and I think that as sim educators we can contribute towards improvment all 4 of these aspects.
From an individual point of view – sim educators can focus on helping individuals deal with acute stress, by training performance enhancing psychological skills – PEPS (as outlined in the paper by Lauria et al, Annals of EM -2017). Stress innoculation training can be used for this. Also “overlearning” as mentioned in this month’s article, can be trained via procedural skills training sessions on part task trainers. Team related factors are generally covered in sim education – but specifically targetting the use of a resuscitation lexicon as dicussed in the article, and explicitly discussing closed loop communication and shared mental models in the debrief could be done. The use of subteams to achieve simultaneous complex tasks could also be effectively practiced in simulation. Regarding environment and system improvements – thats where in-situ/ translational simulation has an opportunity to shine. In fact the use of this is specifcally mentioned in the article.
Regarding your questions
1. To regain control of the resuscitation – Cath would first need to control her own stress. She could use the PEPS techniques of square breathing, positive self talk, mental rehearsal and focus to ensure she is in an optimal arousal state. Then she would need to get control of the team by sharing her mental model of the situation, and allowing others to share theirs during a quick pause point in the resus. For the environment – a senior nurse could be allocated to take the role of the logicstics and safety officer, to ensure optimum functioning.
2. As dicussed above – the aspects brought up in this article could be dicussed more explicitly in the debrief. Deliberate practice of the resuscitation lexicon could be done via dedicated training
3. As with most things taught and learnt in simulation – will certainly affect my clinical practice as well!
Thanks for sharing a great article – looking forward to the discussion!
Thanks for starting the conversation Suneth! It’s great to hear from you again.
I agree it’s a very dense article that has a LOT of learning in it, and it’s definitely going to take me some time to absorb it all.
I agree that as Simulation Educators we have a lot of opportunities to help staff learn to cope with stress in a resus, and while Sim in some ways innately helps with that, I worry sometimes that at the CRM courses I attend, things are kept to a very superficial level, ie. “Was there closed loop communication?”, “Were you aware of your environment?”, “Was there clear leadership?”. And on some level I think a lot of that basic CRM knowledge has already gotten out there now, and people know what to say. I think this paper will help me ‘dig deeper’ in my debriefs as well about the quality of communication and the approach of the staff to emotional containment.
Wonderful article and great case Ben.
I’ve already waxed lyrical about this paper on the podcast, but great to dissect it a little deeper.
I really like how the paper breaks down the individual, team and system strategies, while recognising they are intertwined. Cath would clearly do well with the individual self management techniques described, but the case illustrates how its also the responsibility ( and opportunity) for others on the team to trigger those manoeuvres when they sense distress.
This has already had an effect on my educational practice.
1.Any scenario where there is some measure of cognitive overload on participants I like to discuss those individual techniques (even to medical students), as well as the strategies for re-distributing task work.
2. The ‘sub team systems’ / ‘divisional structure’ is something we’ve also come to in our trauma team training, and are actively encouraging more subteam autonomy to off load team leader.
3. ‘Overtraining’ – last month our trauma sim was… sim – debrief – sim again – debrief again. And we’ll be looking to vary our formats
4. New points of reference for the ‘deeper dive’ discussion in the debrief than how I’ve previously used CRM. I think thats because i’ve interpreted CRM narrowly as a set of behaviours. Good but not enough – and this paper has extended my view and lexicon for that
I’ve still got some work to do embedding some other strategies that I’ve heard Chris Hicks talk about for a couple of years, and we’ll get there.
My only issue with the paper is that i wonder if they should have published as a 3 part series – as there is so much to take in here.
Thanks again
vb
Thanks Vic, I look forward to hearing more about your overtraining!
I agree with you about maybe breaking down this paper into a few more chunks. It’s less a full course meal and more an elaborate 17 course banquet of dense, finely crafted information that defies summarisation.
I wonder whether the limited number of comments this month is in part due to the length of the article?
I’ve read this meaty article a few times now and always get something more out of it. I really enjoyed the way that individual, team and environmental factors were separated, acknowledging that this are never separate.
I’ve passed on the 5 tips for individuals to manage their stress to all of our trainees – perhaps I’ll spark an epidemic of self talk and heavy breathing?
What really struck a chord with me was the way they highlighted the importance of functional team structures and the idea of the LSO – logistics/safety officer. In maternity we lack formal emergency team structures of trauma and some code teams, although our senior midwives frequently function (implicitly) in the LSO role. I have seen this role named “event manager” , but I’m really drawn to the way that the LSO title defines what the responsibilities of that role are. I would like to see this sort of role be more explicit in our teams and I’m hoping we can use sim to teach and rehearse this role.
Thanks for your thoughts Sarah!
It’s great to hear your perspective from an obstetrics background. One of my minor irritations with this beautiful paper is that is specifically brands itself as an article to optimise trauma teams. The principles involved are so universal and important that I think the subtitle of the article undersells itself.
What I’m hearing from your comments is that this article appropriately challenges our perceptions of what specific resuscitation roles can be, and moves it away from a physiological and heirarchical viewpoint, to one in which empowers us to identify the needs of the team more explicitly.
Paediatric Resus, for example, very well often needs a parental communication officer who would not only take a history but reassure/inform parents on resuscitation interventions taking place. I think there’s a lot of power in naming a task like ‘event manager’ in that it provides focus and authority at the same time.
Thanks so much again for your comments!
Hi Ben,
I think there are unique aspects of managing a critical multi-trauma patient that have no equivalent in a ALS/APLS scenario. It is probably the one situation I reflect most often to improve my future performance. I love reading Chris’ reflections on Human Factors which seem to articulate exactly what I have been thinking and why a messy trauma often feels so chaotic.
I think we sometimes under-emphasize how the behaviours of team members can impact on the performance of the leader. Good members can make an average leader appear masterful. Dysfunctional members can push a good leader to her limits.
Not even considering the major clinical decisions (often based on incomplete data) that need to be made, there can be a huge amount of information that needs to be processed in a highly changing situation. This is often exacerbated by the behaviours of junior members in the team or poor ‘follower-ship’. Causes for extreme cognitive overload for the leader include:
1) Having to acknowledge and process several important messages occurring at the same time whilst simultaneously trying to filter out or suppress the clamour of extraneous, secondary or redundant chatter (e.g. ‘I have a CVCI situation’ ‘There pericardial fluid’ ‘I can’t get a pulse’, ‘I’m not familiar with this crike kit’, ‘This BP cuff won’t fit’ )
2) Sequencing the order of several critical tasks that cannot be logistically carried out simultaneously (‘Doctor 1 can you establish large bore access on the right side whilst Doctor 2 begins prepping for an thoractomy on the left side, Nurse 1 – Can you step back and forget about putting a blood pressure cuff on until we get a carotid pulse back’)
3) Micromanaging the performance or decision of team members (e.g. ‘Don’t bother with the second intubation attempt, we need to establish a surgical airway immediately. No. Forget about the LMA’)
4) Resolving conflict between members of the team in a time-pressued situation who often do not work together (‘e.g. we should start the thoracotomy in the resus room and not wait to do it in theatre’)
5) Responding to a rapidly changing situation and then re-priortising or re-tasking people (e.g. ‘the patient has now a shockable rhythm, Doctor 2 forget about the arterial line and make preparations for internal defibrillation whilst Doctor 1 continues internal massage’
More thoughts on Follower-ship”
http://emedsa.org.au/CoreMed/2017/04/01/follower-ship/
Thanks for your thoughts Derek, and I agree regarding the importance of followship, although I think that we seem to be a long ways away from defining what ‘good followship’ is in academic writing.
I agree there are trauma specific nuggets of information in this paper, but I still think it’s shooting itself in the foot by labelling it a trauma paper when I think it’s so much more.
Thank you Ben for a great start for 2018 Simulcast Journal club
I always enjoy reading your case study (you make them entertaining with your unique style of writing 🙂
I have to agree with all the comments about the article being “meaty “and that the material that has been covered in one article can be done over multiple articles. Also the information / techniques in this article can be transferred to all teams NOT just only Trauma teams.
Here are some points that I would like to share with the you:
• Breaking down how to manage complexity in health care systems during (trauma or resus) into 4 domains and addressing each domain equally. This really impressed me as some articles only focus on one or 2 domains and don’t put enough weight in the other domains.
• The article managed to analyse the issues and give practical advice and solutions/options which makes it a very strong article that health care providers across the health system will always use and refer to.
• The following sentences /phrases in the article were the highlight for me and pleasure to read and reflect on and I like to share them with you all :
“A gap between strategy (the plan) and logistics (how that plan is executed) often arises from a lack of consideration for and preparation of the operational environment”
“High-performance teams maintain open and flexible lines of communication”
The authors use a 4-step structured prebriefing process:
What do we know? What do we expect? What we will change? Roles.”
“By examining what goes well in addition to what went wrong, systems can identify elements
of resilience and adaptation that can be applied proactively to prevent error.”
“Resilience is built, not born, and there is no single strategy that reliably manufactures
resilient performance in all circumstances”
• Finally, I think Victoria has brought up a great point of using these strategies and technique during our under graduate simulation sessions. By planting the seed as early as medical school training we are preparing our health care systems and our future doctors very well.
Thanks and looking forward for your end of month rap up session on this article .
Hi Nemat,
Great to hear from you as always.
I enjoyed your highlighted quotes, and agree the 4 step structure for prebriefing is very nice.
Hi team! I’m trying to be good this year and actually read the journal club article rather than rely on the podcast – I think you are on the money Ben with the long article slowing people down, especially as there is so much gold to wrap your head around in the article. I think I am starting to get there though! (So, yes, a three part series would have been nice!)
I also agree that specifically talking about trauma teams very much narrows what is really an otherwise quite broad application. However, with recent literature reviews and other research I have been looking at, sadly this isn’t new – surgeons are much better at publishing (trauma) team training initiatives and programs (closely followed by midwives/obstetricians with ALSO and other courses) than ED or ICU are at publishing ALS/APLS training programs – or other team training initiatives. At the same time though, this has meant that I had to be more reflective while reading through the article looking for parallels with more commonly encountered situations.
I have really enjoyed reading the ways in which in situ simulation can be used for systems and team based applications – both in new and established settings. It is very much something that I want to look at using more in the future. The focus on ensuring positive points, especially from a systems perspective, are used for learning, instead of the usual negative points is something I need to keep in mind. I think it is a matter of taking the generic “what do you think went well?” a step further and prompting learners to think about both why the identified component was “good” and how that can be applied in the future. In terms of my own clinical practice, I have been deliberately taking a moment longer to prepare and focus on complex tasks since first looking at the paper, and so far with positive results.
Thanks for joining us Lauren, it means the world to me have someone come join us in the discussion.
It’s an interesting point you raise with regarding ED/ICU being a lot slower than our Surgical colleagues. Not having done a lit review on the issue I wasn’t aware that that was the case!
What sort of complex tasks have you been preparing for? Did you mean in a clinical setting or in a teaching setting?
No worries Ben – was enjoying the podcasts driving between home (Adelaide) and Mildura doing some rural time this year, and caught up on a lot of stuff over the Christmas break and decided to try to keep more up to date for 2018.
Has been a bit of both really – I have just started my ICU rotation (as an ED reg) so have been doing more procedures than usual – whether relatively new procedures or procedures I had been relatively comfortable with that require variation when the patient is intubated. I don’t have as many teaching responsibilities at present as I usually do, but even so when I have been working with students I have been trying to help them slow down more as well to help them comprehend the complex patients in the unit.
Thanks Lauren, I’m sure the authors will be glad to hear it’s already being translated into clinical practice!
Hi Ben,
thanks for sharing this brilliant paper, which beautifully outlined some helpful cognitive frameworks to help make sense of the complex task of trauma management. I would like to echo the your sentiment somewhere in the discussion thread that suggests that the principles contained within are perhaps more universal might be implied by the authors.
To elaborate further, I wonder if the concepts of managing “Self, team, environment and system” relate beyond management of complex resuscitations or trauma,to the macro level of management of entire emergency department? I thought the concepts were quite transferrable, which is one of the reasons that I found this paper particularly helpful and fascinating to read (…perhaps my interpretation of the article is jaded by the fact that I’ve just finished a set of ED nights in a busy trauma centre).
The two areas that seemed to be most interesting was the section on “stress and performance” and the techniques for addressing this. The two step cognitive appraisal model that they described (i.e. Demand>resource–> threat, Resource>Deamand –> Challenge) is a brilliant way to understand how stress can arise in many ED contexts. Applying this model to the broader context of “running an Emergency Department, for example, with the scenario of a busy department during the middle of a night shift, and ambulance still coming in, it is easy to see how a demands >> resources (cognitive, personnel, and systems-based) situation could easily be perceived, and an appraisal of “Threat” being calculated. The stress management techniques are equally as relevant in this context, as are perhaps the strategies to train to operate more optimally in this setting.
Anyway, just a perspective I thought I’d share.
Great article!
Thanks so much for your thoughts Bishan, it’s always great to hear your perspective. I agree that breaking down the underlying factors that create stress goes a long way to helping us cope with it. What I like about the paper is that it also gives us specific coping strategies to deal with that reality too. Hope you’re enjoying some post nights days off.
In answer to your questions
a) What strategies from this paper might help Cath’s team regain control of a chaotic situation?
You asked this question in an astute way. It isn’t just about how Cath as a leader can regain control over her team but how does the team regain a purpose and direction
i) Someone in the team identifies and categorises the problem and verbalises it -‘Who is leading this code?’, ‘There is too much noise! I can’t hear anything’, ‘I’m receiving too many instructions at once!’, ‘Do we need this many people in this room?!’
ii) Cath need to recognise this as a flag, to slow it down and re-evaluate the priorities. I find it useful just to tell everyone to stay quiet and do a quick recap i.e. what we know, what the priorities are and what we have done. Follow this with with a statement of the unknowns, possibilities and contingencies. This helps everyone get on the same page to help problem-solve with Cath and offer useful suggestions (rather than subversive challenges).
iii) Cath has to juggle quite a few things including not only clinical decisions but also the team’s performance and the constrained environment. She needs to delegate certain activities (‘sub-teams’) or filter out noise and distractions (cognitive overload – non-germane load). This also includes crowd control. Having a strong co-leader who can herd people wandering around important work spaces e.g. drug trolley, medication bench, airway trolley. equipment storage would be really helpful. Emergency services do the same thing with multi-agency responses to vehicle accidents. ‘Stay behind the line, be silent and only come forward when we need you.’
iv) Other useful sub-tasks include a ‘floating’ senior clinician who can help support and micromanage clinical procedures performed by juniors e.g. airway, vascular access, setting up for procedures, troubleshooting monitoring; and a experienced clinician to communicate with and support the family; it is also helpful for a ‘roadie’ to send labs, fill forms, request imaging, make calls, fetch blood products etcs
v) Her team needs to appreciate that communication overload between members and team can occur very quickly in a complex scenario. This in turns adds to Cath’s cognitive overload and impairs her decision capacity. Firstly, it is important that they are all in attendance at the initial pre-hospital reception and remain silent for the briefing. This minimises repeated handovers and re-orientation as new members straggle in. She shouldn’t have to keep repeating herself. As members they need to be careful about shouting out instructions/messages simultaneously either in a non-directed way or having them all converge onto one person, including Cath. Therefore, they need some degree of situational awareness of what other members are doing and being able to triage their own messages. Cath can improve this by keeping the overall team in the loop by outlining the overall strategy and short-term logistical issues. ‘They have an isolated serious head injury. We need to make preparations for transport to CT in 10 minutes, but I want to start the mannitol before we go and we now also switch to portable monitoring’
vi) Finally, Cath also needs to recognise the moment that she needs to stand-down or dismiss staff to simplify the environment
b) How might this paper effect your educational practice and debriefing strategies in CRM?
My general observation is that we often try to cram too much in a sim debrief by addressing BOTH the Clinical issues AND the Human Factors issues. This is particularly true for junior clinicians where often the focus is in KNOWING before SHOWING. Often when knowledge improves some of the recognised human factors issues also dissipate on their own. With improved proficiency, doctors have more ‘brain space’ to address the latent human factors they are sub-consciously aware of but are too cognitively overloaded to address.
Particularly for juniors, I would prefer to spend a session specifically directed to human factors by either making the clinical scenario relatively simple, even trivial. Alternatively, pre-brief the leader about the exact contents of the scenario so they have time to formulate a strategy beforehand. The discussion afterwards is then focussed on team interactions rather than the clinical decisions themselves.
The other component of sim-debrief is that 90% of it is often focussed on the leader’s performance. Traditionally ALS/APLS/EMST scenarios are structured with an ‘all-knowing leader’ supported by a pair of obedient but gormless assistants. This rarely occurs in real life. In fact, many critical scenarios in the hospital are attended by doctors of similar seniority who similarly lack high levels of expertise. The clinical hierarchy is relatively flat. A ‘leadership’ vacuum can occur because nobody feels they exert legitimate authority of the situation (‘He only graduated a year behind me ‘). And if someone does assume that role, there is also a natural tendency in that situation for the rest of the team to assume passive roles (‘Thank goodness. Someone put their hand up. I won’t be the one who screwed this up’).
This under-appreciates how good ‘follower-ship’ even with limited knowledge or experience can still add value to the team and also assist the leader in their function. As part of sim-debrief we need to emphasise this important role. A team member’s speech, behaviours, observations and reactions all have the potential to optimise the function of the team or detract from it.
Thanks for your astute observations and advice for Cath’s team Derek.
I agree that our Sims often focus too much on the leaders, particularly with medical debriefers who focus more on a perspective they can relate to. It’s certainly a weakness I’ve noticed in myself from time to time.
I think sometimes people are keen to talk about good Followship, but don’t know how to, because it hasn’t been a topic of discussion as much and is less clearly defined.
I think a few things help one understand the perspective and role of the Follower
a) As a experienced leader what kind of things you observed your team members have done in the past that helped or hindered your decisions or decision making capacity
b) Understanding the perspective of your team members, how they typically behave in a hierarchical system or complex system and bring that into their daily behaviours
c) Remembering what it was like when you first participated in a resus and the psychological factors (not clinical knowledge) that affected your speech and behaviour
degree of arousal for optimal performance
stress is highly subjective and having icu arive and be seen as judgemental is not helping this stress this is leading to Cath to see Brad as a threat to the resusitation process rather than a challenge this leads to an unfocused approach and they don’t adapt
Traditional training as in the past has been based on the belief that effective teams develop with time, this is different to other high-stakes professions where CRM is seen as important to learn.
Sharing of mental maps is important, however it takes time for teams to share mental models
Self talk leading to cognitive reframing interrupting irrational thoughts
Realise that they are a team including social work managing the family
early strategies to cope p3
knowing team dynamics to align with common goals effectively
mental rehearsal out loud to acknowledge thinking process
steps to manage hyperarousal
How to improve is to factor in ambient conditions. however simulation can leads to scripting and prevents adaptability
concise and direct language
–Sorry, second attempt–
Hi Simulation team, this is a great article to start the year off!
As some of the other comments points to, I think one of the key concepts pointed out by the paper is the perception of ‘is it a threat’ or ‘is it a challenge’. The ICU medical team arrives and she sees them as a threat (even though she is friends with them). In this case the ICU are not part of Cath’s team, they are wanting to take over the situation demonstrated by going straight to the ventilator and checking the settings, undermining her position as being the team leader in the resuscitation. In the end the nurse team leader is able to get Cath back to the case, with the change of how Cathy was percieving the situation from the apparent ‘threats’ in the room to the ‘challenge’ of the case.
The article gives a good explanation of why it is important to believe in your team and from the vignette it is clear that Cath has a diverse team of interprofessionals who all seem involved at this point, however it is her own doubts which hold her back.
A key idea to take away from this article is the importance of thinking out loud in the rehearsal of a resuscitation, thus allowing for the rest of the team to anticipate the needs of the whole team. For example, I was the airway nurse for a trauma resuscitation years ago. The ED consultant was getting the J.Reg to rehearse through her plans for her first intubation. When they had finished discussing the plans the consultant told her to look over to me. She was surprised to see that I had prepared for her plans. His response was “..and that is why we always think out-loud”.
But how to apply this to our practice as simulation educators? I think the key ideas that I have taken away from this article is ‘is it a threat or a challenge’ and that effective teams are not put together, but have to be built through common experiences and training. This is where simulation’s ability to provide a safe and replicable scenario is one of its strengths. The ability to change the complexity of a scenario to meet the need for the situation, allowing learner to be challenged without feeling threatened.
Hey Paul, thanks so much for joining us this month in Jclub. I really enjoyed your comments and interpretation of the case.
I agree that naming ‘threat’ and ‘challenge’ states can go a long way in allowing people to recognise them. Almost like teaching a level of mindfulness in a resus : be able to step back, recognise your emotions, contain them and regain control.
Hi Paul,
An article I once wrote on conflict resolution in the resus room:
Maintaining your Command
SATURDAY, 5 MARCH 2016
The Novice Team Leader faces a daunting task in her new role. Whatever personal preparation she may have undergone, she still needs to meld together the collective efforts of members of her team each with their own specific set of experiences and skills who may be unfamiliar which each other’s strengths and weaknesses. In the dynamic and decision-dense environment of a resuscitation, minor or even major disagreements about clinical management can occur. Priorities of care often need to be juggled and rearranged. Conflict between team members and with the leader can easily derail the process. Critical situations naturally attracts high-functioning individuals, often with strong opinions that may not always be synchrony. Within their domain they may even have superior experience over that of the leader. This can be particularly problematic where teams are assembled ad hoc from a mixture of different departments. Being able to manage this requires excellent situational awareness, good communication and of course, sound clinical knowledge and judgement.
The team leader can err into two extremes when faced with dissenting or disruptive behaviour. Either they aquiesce to the most dominant (or loudest) participant or they attempt to vigorously suppress their involvement. The risk of the former is to divide the loyalties of the group, create confusion and introduce delays to definitive care – and importantly create an unhealthy precedent by essentially rewarding insurrection. In the latter, the leader may alienate the individual from contributing usefully at an important juncture. At times, a firm direction needs to be taken at critical moment but always making it clear that this is only a temporary injunction before re-engaging those who may have felt excluded or ignored.
However, even in the fast paced world of the resuscitation room there is always room to discuss concerns, objections and alternative options. In fact, a mature team should always be able to challenge the leadership without necessarily disrupting its authority. This also presents as a safeguard against dangerous, irrational or misinformed behaviour. Both followers and leaders need to be able to justify their decision through a careful recitation of the information at hand and explain by what means they achieved it. Nevertheless, often disagreement is the natural result of working in an environment where there is incomplete and missing data to form a confident decision either way. In these situations, after appraisal of everyone’s opinions, it is ultimately the leader’s decision that needs to be followed without reservation or obstruction. To be able to achieve this without losing the confidence of the team is to first acknowledge their concerns and accept that if these eventuate that a contingency plan may need to be followed. Either way, the leader needs to impress upon everybody that in any situation she needs the complete participation and assistance of her team.
Following is an example in practise.
A construction worker is brought to a major trauma centre after having an iron girder fall across his abdomen on a Saturday morning. The Trauma Team is activated. On arrival he is mildly tachycardic but apparently normotensive. Capillary refill is mildly sluggish. His is complaining of severe pain over his left upper quadrant where an obvious bruise is noted and a tense abdomen. Despite a litre of crystalloid administered by the ambulance crew, his vitals remain unchanged. Initial CXR and PXR appear normal but FAST scan reveals a large amount of free fluid particularly around his spleen. The provisional diagnosis of splenic rupture is made.
At this point the Trauma Leader feels that the amount of blood on FAST suggests that the injury is significant and that immediate laparatomy is required to control bleeding. There does not appear to be any other immediate needs beyond this. The senior surgical registrar wants to obtain a CT scan with a view to possible interventional angiography.
Clearly surgery cannot proceed without the surgeon’s involvement. At the same time, sending the patient for a CT or angiography is risky without the full resources of the resuscitation team and potential need to continue administer blood product there. An ongoing disagreement forms between the Trauma Leader and Surgeon leaving the supporting clinicians and staff unsure about the transfer of the patient. Minutes tick by…..
The Trauma leader feels uncomfortable about the logistics of continuing a resuscitation in CT and particularly organising emergency angiography over the weekend – and that surgery would be more expedient and predictable. The Surgeon feels the patient is stable enough to get potentially more useful information and potentially salvage the spleen. They both agree that time is of the essence here and that the patient is in urgent need of some kind of intervention. In the end they strike an agreement, the Trauma Leader agrees to go to CT as long as the Anaesthetist is to also move with the patient and assist in ongoing resuscitation. She also wants the Surgeon to anticipate the need for angiography and minimise delays by calling the Interventional Radiologist himself to be in attendance that he may be able to activate the angiography suite immediately following the results of the CT. She also wants to get agreement from the Surgeon that if the CT show catastrophic or multiple injuries, the plan for Angiography be abandoned. Similarly, if the patient destabilises significantly in CT despite aggressive blood product replacement that scanning should be immediately stopped and that moves to the Operating Theatre should occur. Theatre is asked to remain on standby. This plan is conveyed to all members of the team. The Surgeon agrees to this.
Ultimately, the CT is completed but not without a tense moment where a transient fall in blood pressure and fair amount of blood product was given. The Radiologist provides a hot read from the console (as requested) and notes on a Grade IV splenic injury with contrast extrasavation and minor laceration of the left kidney. With both Surgeon and Interventional Radiologist also in the CT room, the patient is swiftly moved into the Angiography Suite with the Trauma Team which has been already been set up in preparation. Everyone watches in anticipating as the offending vessel is embolised expertly, bleeding controlled, and the spleen saved. Followup CT showed no further injuries requiring operative intervention and the patient experiences an uneventful hospital course.
In summary, respectful communication, sound clinical reasoning, contingency planning and careful logistical control led to a good patient outcome. Meanwhile the integrity of the team was maintained and the mutual respect of all those involved.
Hi Derek,
Thanks for providing the article, it definitely demonstrates the need for clear communication and making sure everyone is aware of the rational for a decision. Having the Trauma leader present the problem, however also giving the solution (happy to go to CT, however a resus team must also attend with the anesthetist) I think shows that her concern for the safety for the patient but also acknowledges that the CT may provide more definitive diagnosis for the surgical team.
Thanks for a great read!
Thanks so much for this evocative read Ben. As an ED Registrar and more recently as a Sim educator, there is so much I can take away from this. Admittedly my palms were sweaty by the end of reading the first scenario; every ED doctors worst nightmare!
I do think it’s easy to become complacent about rehearsing teamwork scenarios both in Sim training and other forums. I realise it’s something our department does quite well compared to previous ED’s I’ve worked in. However, there is always room for improvement. Trauma is certainly a team sport. But so are all resuses in critically unwell patients. It appears to me the key is preparation and an unflappable team leader. I particularly enjoyed reading about the strategies one can employ to remain resilient and focused.
Hi Sophie, thanks so much for coming along and joining the journal club.
I agree that having an unflappable team leader is powerful, and I love the way this paper explores ways to achieve that rather than just saying ‘be unflappable’.