Charlie Foxtrot in the trauma room

[fiznat]

I was in the ED today dropping off a patient when I overheard a patch on the c-med radio saying that a trauma was coming in. ...GSW, 4 shots from a handgun into the patient's back, through the torso, and 4 exit wounds out the chest. You can hear yelling from the back of the rig as the driver is giving the patch, he reports that the patient cannot move his legs and is beginning to become combative as the hypoxia and blood loss begin to take hold.

The crew did a good job. The patient was spine-neck immobilized, the chest twice decompressed, IV established with fluids running, O2 provided along with assisted vents via BVM. Sinus tach on the monitor, and the little bleeding seemed to be well controlled. ...All this performed with a combative patient and --as I was told later-- a group of rowdy onlookers on-scene. It wasnt until they rolled into the trauma room that the chaos began to ensue.

Seriously the worst cluster I have ever seen. Had to be 15 ED docs, nurses and techs cramped into a trauma room designed for probably half that. Immediately people start yelling. "Get me gloves!" "Get this guy tubed NOW!" "Give me a blade! Give me a blade! Give me a blade!" People are pushing each other out of the way, lines are crossed and steps are missed. I watch a resident insert a chest tube and then - once its inserted - look around and wonder where the rest of his equipment was. He didnt set it up before cutting, so he starts yelling for it. Nobody gets any respect. Nurses are treated like idiots because they dont instantly provide equipment to doctors, techs are pushed out of the way as they struggle to help. Everybody is yelling.

By the time it was said and done, this patient got his chest cracked right in the bay, tubes inserted and lines of blood run. Probably 10 minutes in the trauma bay and he was rushed up to the OR. As the bed was rushed out of the room, the femoral line almost gets pulled out as the bags of blood fall to the floor. Someone gets knocked down.

I have never ever seen such horrible communication and teamwork before. This was not a trauma team, as the called for on the intercom, it was a collection of bigheaded doctors and angry nurses-- each screaming to have their voice heard over the chaos.

I've seen this trauma team work patients before, but not like this. Usually it is a moderate trauma -- an MVA or a fall. This GSW was one of those rare and fantastic traumas: the kind you get to pull all the tricks and procedures out for. Hell, the medic got to decompress the guy in the field -- twice! How often does that happen, right? ...But the rarity of it and the added stress seemed to take the trauma team and fracture it. What is normally a cohesive team performing organized assessment and treatment became a frantic collection of angry demands and rushed decisions. Not exactly what you would hope for if you were that poor patient on the stretcher.

Anyone ever seen this before? How does your ED trauma team work? Do you find that doctors tend to yell over the crowd as the issue demands, or is there actual calm collected teamwork? ...Even on the bad traumas? I know we struggle with this all the time in the field-- and I'm sure most of us are familiar with that whipped-up exciting urgency that can sometimes become overpowering on the really bad calls.... but we all consider it to be the mark of a good medic/EMT/firefighter to be able to rise above the chaos and organize. It bothers me that these (mostly) experienced ED physicians found this basic principle so difficult to achieve.

I have 5 years of experience in EMS as an EMT and now (almost! haha) a medic, but I have never seen this kind of frantic response before from an ED trauma team. I know this is a long post and a long story (I tried to make it interesting), but I'm interested to hear other people's observations of bad traumas run in the ED. Whats the best youve seen? The worst?

[Asysin2leads]

Send 'em over to the ED Marines at Bellevue or Kings General. They'll have them whipped into shape in no time.

Real quote from Bellevue: "You were just shot in the face, and now you're giving me a hard time about getting an IV?!?!?"

[JPINFV]

My local university trauma center has a set of rules posted in big letters on the wall of the trauma room that includes who goes where and who does what.

[neoboi]

i would like to mention that this sounds like the eden medical center trauma room in castro valley, ca.

[Dustdevil]

Real quote from Bellevue: "You were just shot in the face, and now you're giving me a hard time about getting an IV?!?!?"

Real quote from Parkland ER in Dallas:

[becksdad]

LOL! ... That guy from Parkland ER sounds like a candidate for "social intubation"!!

Honestly , though, I can't think of any trauma calls that have been such clusters as described. Even ones that I have been allowed to assist with have all gone very smoothly, very professionally. I'm actually surprised at what you describe, Fiznat, I have never seen a Trauma Team thrown like that.

[zippyRN]

rules of trauma teams

-no baby docs ! EXCEPT Emergency Dept ones specialities wise - middle grades or seniors or don't play... and we will throw the baby docs

- one voice at a time and most of the time that will be the Emergency Doc who is team leader or the Senior Nurse

- as few hands on the patient as possible / sensible

- if a doc spits the dummy expect to be thorown out by the team leader and spoken with by the senior nurse...

- the person with the head calls the shots over moves and hands regardless of 'rank'

[Doczilla]

It shouldn't happen like that, but it will if any of the following are true:

1) They don't run a lot of bad traumas and aren't very practiced at it

2) The attending at the head of the trauma team doesn't take control, set the tone, calm everyone down, and assign jobs

3) The charge nurse doesn't thin the herd, assign jobs, and keep track of everything

A given is that any trauma center should all the equipment needed and near the bedside, which many places solve by having a large rolling cart with chest tube trays, thoracotomy trays, line kits, advanced airway, sterile gloves, and a variety of other stuff. It is important that nurses and physicians know what is on this cart and where so they are not searching for it at the wrong times.

You're going to have folks like radiology pushing their way to the middle to get the cxr, lab pushing in to draw the blood, registration trying to get the info to register the patient, etc. They sometimes feel the need to announce to everyone in the room that they need to do this or that or the other. This is all easier when they instead first approach the doc who's running the trauma or the charge nurse. They can decide if it is really imperative to get that cxr right now, or the charge rn can tell one of the nurses who is starting the IV to get a syringe full of blood for the lab. In either case, they can move the troops to give these other folks the room to do what they need.

It is in these situations where good leadership is key just as much as good management. The head trauma doc, if there is at least one other doc to do procedures, should stand at the back of the room and take it all in, prioritizing procedures and orders and recognizing what equipment is needed, redirecting the other docs (usually residents) as needed. The charge nurse fits best in the recorder position, writing everything down on the flow sheet, requesting additional resources, calling for the x-rays, etc. and kicking people out of the room when indicated. These two folks have to set the tone for the resuscitation through tone of voice and through demeanor. If they don't look all excited, then everyone else will chill and do their jobs like they are supposed to and like they were trained to. When things are getting hectic, speak SOFTER, not LOUDER. This forces people to shut up to hear you, and discourages them from yelling also. And the overall effect is to calm everyone down.

What is important to realize is that there are really 2 procedures that require INSTANT action: securing the airway, and decompressing the chest. Chest tubes are nice, but if you can decompress the chest, the chest tube isn't critical. Even central lines, particularly if there is good peripheral access, can wait.

Delegation of tasks will help this whole situation. Pick someone and put them in charge of the airway. Tell them they need to get what they need and intubate, and don't bug them while they do. The thing with chest tubes is, if the person doing it has done only a few, they are probably concentrating on the procedure itself rather than the setup of the pleurevac. Put someone in charge of the chest tube, tell them to get one helper to set up the pleurevac, and let them do what they need to do. Likewise, requests from the folks who are on the patient (like for 4x4s or syringes or thoracotomy trays) are best directed at the charge rn or attending, who can make that happen by handing it to you or delegating it to someone. And every once in a while, the attending doc or rn has to tell everyone to shut up.

The same principles apply to really s#itty calls in the field. Use the leadership to your advantage. As the leader, keep the big picture, and get off the patient. As one of the assistants, do what you need to do and open your mouth only when necessary.

'zilla

[Tracyd1]

Our trauma teams are awesome. The mood is always efficient and effective. The one thing they do have is a line of tape all the way around the bed, if your not doing a procedure then you can't cross the line. That works very well as far as congestion and then the doc just hollers out his questions to us when neccessary about the scene and so on. We do have a school of medicine here so there is always an over abundance of residents but they all do a good job with keeping it calm. The nurses will also tell the docs where to go and give them explicit directions on how to get to that location and what to do with themselves while they are there. Kind of funny to watch the residents get broke in so fast:)

[AZCEP]

The best I've ever seen was the time the attending met our ambulance in the ambulance bay--outside the ER--jumped in the back and we worked the code for 10-15 minutes before we decided we should probably move inside. When we did, the entire staff was standing outside our ambulance since they couldn't get into it. They just stood there wanting to do something, but there just wasn't any room for them.

The worst was at the regional trauma center. My partner and I activated for a fall from ~12 feet. When we arrived there must have been 30 people standing around the bed. As we go to lift the patient over to the ER bed, one of the "team" grabbed the board, and promptly jerked it out of my hands. Board crashes to the floor between the bed and our gurney. I looked at him and asked if he was quite done with helping us. The attending made him sit at the nurse's station for the remainder of the shift.