Estimated reading time: 17 minutes
I was incredibly privileged to be asked to speak at the RCEM CPD conference today in Bournemouth. This blog post details some of what was discussed with links to all the further resources that I mentioned.
Those first few bars of music… Even now I can picture my teenage self, in front of the telly on a Wednesday evening, imagining where I could in thirty years time. I watched in awe as Mark Green, Susan Lewis, Carol, Doug, Benton and Carter went about their work. I don’t know about you, but this is what I always imagined my future in Emergency Medicine and Trauma care to be like. All action, heroic life saving. With me there in the middle of it. Cool, calm, knowledgeable and yet vulnerable and humble. An everyday hero.
Of course the truth is something rather different. And much of our time isn’t taken up with pushing gurneys down corridors, ordering a ‘Chem 20’ and everything happening ‘stat’. However, I think there are things we can actually learn from the telly.
But before we talk about the here and now, we need to briefly go back intime, to what started all of this.
The year is 2007, and I am a final year registrar in Emergency Medicine. That year the National Confidential Enquiry into Patient Outcome and Death published ‘Trauma, Who Cares’, perhaps one of the most influential reports of the last few decades, and arguably the biggest single driver to change trauma care in the UK.
Some of the reports conclusions were damning:
- Less than half of the almost 800 patients received what would have been described as ‘good care’
- Pre alert from the ambulance crew was documented in less than 50%
- One in five hospitals did not have a trauma team
- Even after a pre alert there was no trauma response in a quarter
- Consultant was team leader in only 40%
- 40% not seen by a consultant in the ED
- Initial management thought to be inappropriate in 13.4% of cases
This lead to a series of recommendations, many of which will seem commonplace today, but the one we are going to focus on is this: A consultant must be the team leader for the management of the severely injured patient.
But before I go any further, I have a confession to make. Perhaps it was the arrogance of youth, but I really didn’t think this was a big deal. Lead a trauma team you say? No problem. How hard can it be? All I have to do is stand there and tell people what to do. Of course they will listen. Of course my patients will get good care. This report isn’t for me – it’s for everyone else. Only later, after making countless errors, not necessarily in the actual medicine, but in being a leader, would I see how wrong I was. This is my confession and in an attempt to atone for some of my sins, here are a few of the things I have learned over the last decade or so…
Scene 1 – Preparation
Picture the scene. You are in your Emergency Department when you hear a pre alert….
I’m guessing that when you hear the prealert you hear it in one of two ways. Some of you will hear it as if Chegger’s himself is calling you into Resus. There is nothing more exciting. Let’s go. But a large number of you will also hear it as if it were an Alan Bennett monologue, where you would actually be more excited if you found a cracker under the sofa.
Because you see, a lot of us are introverts. I know that’s not the common perception of the adrenaline fuelled emergency medicine doctor, but we really are and here is some ‘science’ to prove it. But people like us, and yes I am an introvert too, are in good company. Every single person here describes themselves as an introvert, but are able to perform on the biggest of stages. If they can do it in front of 100,000 people at Wembley stadium we can do it in front of a trauma team of slightly fewer.
Just because the mere idea of social interaction strikes fear into your heart, doesn’t mean you can’t be a superb trauma team leader. All we have to do is put on a bit of a show and be prepared.
Preparation is key to be a good trauma team leader and happens long before the chimes of the prealert ring out across the ED.
Cliff Reid, formerly of this parish and a one time graduate of the Wessex training rotation and now a leading light within the world renowned Sydney HEMS devised the Zero Point Survey to help give a framework to this preparation.
It’s called the Zero Point survey, as it comes before the Primary Survey. It accentuates that being ready to treat a trauma patient whether in the prehospital environment or in the resus room starts before the ABC. Cliff has produced an excellent video which explains all of his thinking about the Zero Point survey, Let’s start by thinking about the first three aspects – Self, Team and Environment.
As with all things any trauma starts with you – are you ready? Are you in the best place to lead this team? This not only relates to your experience and training, but also how you look after yourself. You have to be at your best – are you tired? Are you distracted? Do you need a wee? At the end of every HEMS briefing our pilot always asks the same question:
“Are you adequately rested and fit to fly?” This is the question we should all ask ourselves before every shift, at regular intervals during our shift and before any caring for any acutely unwell patient. You need to be at your best to give your best.
Now, I realise that in the current climate the only real chance you have of being fully rested and fit to fly is if you have just started your first shift back after two weeks of annual leave spent in an email free, social media free, bubble on a Caribbean island, but we can be honest with ourselves and our colleagues and makes sure we do the simple things well: eat well, get your sleep and spend some time looking after ourselves.
All the things I am about to talk about are techniques I have found to mean that running trauma calls place as little stress on me as possible and it’s here where my first script comes in.
Throughout leading a trauma team I have several scripts that I have refined and memorised and use in every case. Every case, even if I know the team really well, or we’ve just done a trauma together minutes before.
I will wait for the team to gather in as complete a fashion as possible, I completely understand that certain team members may be delayed in attending. During this time I’ll introduce myself and encourage them to put on a gown with a sticker for their role and name and ask them to stand next to the part of the trolley where they feel most comfortable.
Then in my head, the performance begins and I take on the role of trauma team leader, all with a prepared script.
Scene 1 goes like this…
“Hello everyone, I’m Iain Beardsell, one of the ED consultants and I will be the Trauma Team Leader
We are expected a patient in some minutes with the following pre alert
Their age is blah and at such and such a time they had this happen to them.
Their injuries are this and that and the signs are these. They have had this treatment and are due into Resus at this time.
Has anyone got any questions about what we are expecting?”
The aim to share as much information as I think necessary to the whole team at the same time, so we all have the same information.
Next comes the rest of the team.
“So please could I ask you all to introduce yourselves to the team and your role looking after this patient.”
We go round the group and I prompt everyone to introduce themselves. If anyone hasn’t got a sticker with their name on I gently ask
“Please could your write your name on your sticker, I’m afraid at my age I won’t remember all of your names”.
Finally in the preparation episode, comes the mission rehearsal, where I make sure everyone knows what will happen, regardless of whether this is their first trauma call or their hundredth.
“So when the patient arrives, I will ask if the patient is ‘stable for a hands-off handover’. If they are we will park the patient up next to our trolley and all listen to the handover. Please listen carefully and always remember that the prehospital team may well been in a really difficult situation over the last few hours and we want to support them as best we can. If the patient isn’t stable, I will ask the prehospital team to continue team leading until such time as we can take a handover.”
I finish with
“Please remember that a quiet trauma call is a good trauma call. If there is anything you need, or anything that concerns you please ask me, my name is Iain and I will make it happen or think through your worries with you”.
Now before we go onto Scene 2, I just want to pause to make two really important points. The first is regarding how you treat the arriving prehospital team. As alluded to in the script, it is often impossible for us to even imagine the challenges that they have faced before arriving in our nice, bright clean Emergency Department. They could have been on a roadside, in a ditch or in a cannabis smoke filled house. It’s a small team, and they don’t have the luxury of calling up a ‘specialist’ to check what they are doing is correct or to ask advice. The last thing they need is you, in your resus room, criticising their care, or even implying there might have been something they should have done differently.
I will never forget taking a patient into Resus at my own hospital after a difficult prehospital period, which included a rapid sequence induction of anaesthesia, only for the Anaesthetist to loudly proclaim when the team leader asked about the airway that
“the tube was down the right main bronchus, but don’t worry I’ve sorted it out”.
Whether it was meant to, or not I took that as a direct criticism of me and my care of the patient in front of my own hospital colleagues.
Scene 2 – The Patient
The second thing I would strongly advocate is the ‘hands off handover’. As discussed in the mission rehearsal, as soon as the team arrive and I have made eye contact with the person giving the handover I will say
“Hi. I’m Iain, I’ll be the Trauma Team Leader, is you patient stable for a hands off handover?”.
I don’t transfer the patient onto the hospital trolley and, assuming the patient is stable, we all listen to the handover. I’ll gently stop any other activity that happens, even if it is just taking a pole out of the end of the trolley. For that minute, the prehospital team has our, quite literally, undivided attention.
Now comes the actual medicine. So far, we have managed to completely offload our brains, with good preparation and a script. All of this has been in preparation for this moment, when we need to have all of our brain to think. If scene 1 has gone poorly, there is absolutely no way you will be able to the next bit, the improvised section well.
To try to make this as simple as possible I have boiled everything I need to ensure happens into this one equation. The absolute crux of resuscitation – the delivery of oxygen to tissues. This is my prime concern and by addressing the CABC I will make sure this happens. I often say to medical students in resus that my job is purely as a facilitator of the production of ATP. Yes, I know it is slightly more complex than this, but at it’s very essence this is what we all do.
There are a few things I have learned about what to do during this scene.
The first is to always be trying to think several moves ahead, like all the very best chess players. Will the team is doing the primary survey, I am always thinking about what is going to happen in a few minutes time, “Do we need an arterial line? If so, who will I ask to do it? Where is the transfer stack? Is the patient booked in and the CT scan requested”. And each and every time I need something doing I used closed loop communication and the person’s first name. Never, ever say “can someone get me”
The second is the use of time based targets, something are perhaps all rather used to in Emergency care. Giving the team explicit times that I think we should have certain tasks completed by: the most obvious of these is I want to be in CT by such and such a time. It isn’t just my work that helped me realise how much this helped, but my role as a Dad too. In fact I see getting a patient to CT or theatre in a very similar way to how I need to get Rufus out of bed and to school in the morning.
Humour is a very difficult skill to judge and needs to be used with caution. This is a team who you may have only just met. They may not appreciate your dry wit, or realise that you actually really think orthopaedic surgeons are clever. Never, ever put anyone else down in any way.
Never forget that for some, being part of a trauma team can be incredibly scary and intimidating. This maybe your fifth one that day, but for others it may be the first they have ever seen. For someone as old as me, it is really hard to remember what it was like to be a new doctor, faced with a really poorly patient. Ask your colleagues how it can feel – if you understand them more you will be better able to get the best from them.
Touch can be a very powerful tool in persuasion. If you need to get someone’s attention a simple hand on the shoulder can be enough and that physical connection helps make things happen. Please note I am not suggesting that you start hugging other members of the team indiscriminately.
And lastly, do not get angry. If you find that when trying to discuss with your general surgery colleague that you patient needs theatre you end up raising your voice or even saying this,
you have lost the team and you may not get them back, either for this trauma, or when working with them in the future.
Scene 3 – Progression
Throughout all of this the main job is to maintain momentum and make things happen. After the initial excitement and anticipation, this is the point where sometimes you need to make sure you still have the team’s attention.
This brings us back to Cliff’s zero point survey for the final two parts: the ‘update and priorities’. It’s absolutely crucial that you keep the team informed just enough about what you are think, but balance that with not overloading them with too much information.
We now move to the final scene of our three scene drama: Progression.
We have all the information we need from the primary survey and any interventions that are required have taken place and we want to get them to CT. Or we have got as far as we can and simply need to move the patient to theatre.
Often I’ll reiterate, or modify, the time target we set before, but as soon as I think we are ready to go, I’ll start the transfer checklist. You won’t be surprised I have a script for this too.
Now I know that some do not like the idea of checklists, but you’ll have realised that throughout all of this I’ve tried to stick to a format so that I leave plenty of space in my brain to think about the tricky stuff. After all, we all think it’s ok to go to the shops with a checklist, so why not before you go to CT with a patient with potentially life threatening injuries.
I always introduce the checklist in the same way.
“Thanks everyone. Let’s do the transfer checklist to make sure we are safe and ready to go to CT. This is a challenge/response checklist so when I call it out please say ‘yes’ if you believe it has been done’.
I run through the checklist and try to make eye contact with each of the individuals who I believe are responsible for that item.
When it is complete I will say:
“Our primary plan will be to go straight to CT, and get the scan completed. If at any point we are concerned that the patient isn’t stable enough to get there we will simply come back to this Resus Bay and continue the resuscitation while we make other plans.
Please remember that we need to be quiet when we are in the scanner and everyone except myself and the anaesthetic team will need to stay outside, to allow the radiology team space to concentrate. If we need you urgently I’ll call you in.“
Has anyone got any questions?
Thanks so much everyone. Let’s go.”
For me, this is often the hardest part of any trauma call. To keep the team interested and engaged. I do think it is really important to make sure we respect the radiology team. All too often I have seen the relief of getting to CT manifest itself as too much chatter and joking around, and more than once have been asked to be quiet.
After focussing on leadership, I just want to mention followership, which I think at times can be even more important.
There will be times when you are a team member and not the leader. In this situation you have the power to be even more influential, in both a positive and negative way. You have to find a way to be supportive and encouraging, whilst also helping move things along and not take over. Often it is in these moments where your role modelling is at its most crucial.
And lastly, this stuff isn’t easy. You need to practice and you need to be watched and given feedback and advice. This is perhaps the hardest part of any learning process. None of us like to be told we’re not very good at something, or even that we’re not the very best at something. But this is truly the only way to get better.
And as with all the best TV shows, the time has come for the end credits.
- Think about yourself, the team and the environment. Are you fully rested and fit to fly?
- Use a script and play a part. Whatever your personality you can be the leder the team needs
- Thinks ahead; set time targets; don’t get angry and use humour and touch carefully
- Checklists really aren’t cheating. They just give your brain space to think
- Practice, practice, practice and be watched whenever possible.