Surgical Critical Care,  Trauma Surgery

The Trauma Team Management

Talent wins games, but teamwork and intelligence win championships

Michael Jordan

Trauma Squad!

Luckily, or unluckily, when we speak about major European Trauma Centers, patients (PT) are managed by “trained” teams. Based on our experience and courses we learned two different ways of managing the team, depending on the situation and the team members (TMs) you may have. Obviously we will explain two extreme situations, one black and one white, with all the different shades of grey in the middle.

The Vertical Approach

The first approach is more close to the ATLS way of thinking, the Team Leader (TL) will be hands-on the patient while the other team members will just do the support. 

Let’s see how this could work:

  • Head member (HM): his/her role will be to closely check the spine motion and control the movements or translation of the patient from one stretcher to another. This member should also check for changes in the mental status while the TL is managing other things.
  • Vitals’ member (VM): his/her role will be to connect the PT to monitors on arrival and follow them during the whole resuscitation, get one IV line, and eventually start fluids on the TL command.
  • Procedures’ member (PM): his/her role is to set up the second IV line, draw blood for laboratory tests and ABG, he/she should also be ready to help the TL in case of procedures (intercostal-drains, pelvic binder, E-FAST, urinary catheter, etc…).
  • Writing member (WM): this member is not essential, even though he/she may be extremely useful. While the TL performs the primary survey he/she is in charge of writing down every finding and every procedure done during resuscitation. The timetable should be reported as well.
  • Team Leader (TL): as we said, in this scenario, the TL is literally hand-on the PT. After receiving information from the rescue team, he/she performs the primary and secondary survey of the patient, speaking out loud the findings and the PT needs. 

Here is a practical example:

A – 47 yo male

T – 06.30

M – Frontal motor-vehicle accident (car vs. car)

I – Right chest pain, diffuse abdominal pain

S – BP 100/65; HR 115 bpm; SatO2 95% in room air; RR 28 breaths per minute; Temp 36.5 °C; GCS 13/15

T – 18G IV-lines (2x), 500 mL Ringer Acetate, fentanyl 50 mcg, oxygen supply

On patient’s arrival, the TMs help the pre-hospital team to move him to the trauma bed while the TL receives information from the pre-hospital doctor.

The HM checks the stability of the c-spine, the VM connects the PT to the monitors, while PM sets up a third line to draw blood tests.

Now the TL is free from the pre-hospital team and performs the primary survey speaking out loud the findings so that the WM can write down the charts:

A – Airways patent, no C-spine tenderness

B – Pain on the right chest, reduced lung sounds on the right side, ICD inserted (helped by PM), RR 24 and SatO2 98% on oxygen (FiO2 35%) after drainage

C – Diffuse abdominal tenderness, seatbelt signs, pelvis stable, BP 95/54, HR 120

D – GCS 12/15, pupils equal and reactive to light, no lateralizing signs

E – Logroll negative, Temp 35.7°C, active external warming

E-FAST – left pneumohemothorax, abdominal free fluid (perihepatic, perisplenic and in pelvis)

CXR & PXR – left pneumothorax, ICD in place, pelvis stable

ABG – pH 7.30, HCO3 17.4, pO2 87 mmHg, pCO2 34 mmHg, Hb 10.7 g/dL, Lac 9 mmol/L, BE -10.7 mmol/L

The TL decides to ask for blood products and take the PT to CT scan. In the meantime, he calls a second surgeon due to the high chance of needing surgery after the CT scan. 

The PT is brought to the CT scan and, while the TL monitors him, he has to speak to the radiologist to explain the case, call the OR to say what to prepare, the neurosurgeon to check the scans, and the laboratory to have the blood tests results.

As you can imagine the only really trained member in this scenario is the TL, who holds both resuscitation and information. The level of training of the other members may be low without affecting the resuscitation. Usually, WM, VM, and PM are nurses, while HM may be absent or, if you have a second doctor in your team, he/she can cover this role. 

The WM may be a doctor as well, but usually fairly experienced.

The Horizontal Approah

The second approach is on the extreme opposite: it needs a very well trained and synchronized team to properly work. In our opinion, it is harder to perform and achieve, but it would be worth the effort. Here the TL will be hand-off the PT, while the TMs will proceed and do the primary survey. This is a bit more complex to explain and imagine. This approach is taught by the European Trauma Course.

Before we start, it must be said that each member of the team should be a doctor and, at the full team, each doctor should also have a nurse. We are speaking about 8 people! 

To fully understand what should happen, you have to rethink the primary survey (ABCDE), each member will focus on one letter (A+D, B, or C), while the TL will take decisions based on what the team reports. 

But let’s focus on each member:

  • A+D: as you can imagine the role of this member is to check the Airways and the Disabilities of the patient. His/her role should also be to perform the intubation if needed.
  • B: this colleague will check the Breathing status, the chest, and will perform the needed procedures (insert intercostal drains or thoracotomy). He/she should also connect the patient to the monitors.
  • C: he/she will be in charge of controlling the bleeding status (connection to monitor, draw blood, set up IV lines, positioning the pelvic binder, performing the E-FAST, and so on).
  • TL: as we said, he/she should be hands-off. Before you read the example, this is what the TL should do: on PT arrival, he/she should perform a rapid evaluation to check ABC (this should not take more than few seconds) before handing the PT to the colleagues. Right after, the TL should receive information from the rescue team, while the “hospital team” performs the primary survey. At this point, there should be a stop: the TL reports the important information to the team and each TM reports his/her evaluation to the TL. TL should now give orders to the TMs saying what to do with the PT. 

In this way of working the TL holds the most of the info, and he/she leads the resuscitation by coordinating and anticipating the PT’s needs (does the PT needs an operating room, an angiography, a CT scan, an orthopedic, a vascular surgeon, or something else? The TL has to coordinate this, while the TMs treat the PT).

Again, let’s review this way of working with an example, using the same patient as before:

A – 47 yo male

T – 06.30

M – Frontal motor-vehicle accident (car vs. car)

I – Right chest pain, diffuse abdominal pain

S – BP 100/65; HR 115 bpm; SatO2 95% in room air; RR 28 breaths per minute; Temp 36.5 °C; GCS 13/15

T – 18G IV-lines (2x), 500 mL Ringer Acetate, fentanyl 50 mcg, oxygen supply

On patient’s arrival, the TL checks the PT status (he speaks, is breathing and the distal pulses are present). The TL hands the PT to his team.

The TMs help the pre-hospital team to move the PT to the trauma bed, while the TL receives information from the pre-hospital doctor.

In the meantime:

  • A checks the airways, the stability of the c-spine, calculates a GCS of 12, finds pupils equal, and no lateralizing signs;
  • B connects the PT to the monitors, finds a right pneumothorax, and inserts an ICD helped by his/her nurse;
  • C draws blood’s tests, finds a tender abdomen, seatbelt signs, pelvis stable, and performs the E-FAST;
  • All together they perform the log-roll.

Now, the TL is free from the pre-hospital team and calls for a stop. He reports the ATMIST to the TMs and right after they report their findings back:

  • A: I’ve found Airways patent, no C-spine tenderness, GCS 12/15, pupils equal and reactive to light, no lateralizing signs
  • TL: Perfect, keep on checking
  • A: Ok
  • B: I’ve found pain and reduced lung sounds on the right side, so I’ve inserted an ICD. The RR is 24 and SatO2 98% on oxygen (FiO2 35%) after drainage. I will need a CXR
  • TL: Call for it and for the PXR as well
  • B: I’ll call for the X-Rays
  • C: I’ve found diffuse abdominal tenderness, seatbelt signs. The pelvis feels stable, BP 100/54, HR 115, Logroll negative, Temp 35.7°C. I’ve activated external warming. On the E-FAST I confirm the right PNX; moreover, I have free fluid on three abdominal quadrants 
  • TL: Ask for blood products and help B with the X-Rays
  • C: Ok

The TL reads the ABG results to the TMs while the X-Rays are taken:

ABG – pH 7.30, HCO3 17.4, pO2 87 mmHg, pCO2 34 mmHg, Hb 10.7 g/dL, Lac 9 mmol/L, BE -10.7 mmol/L

CXR & PXR – left pneumothorax, ICD in place, pelvis stable

The blood products are on the way. The TL has the time now to call the radiologist and speak about the PT, while the TMs bring him to the CT scan. During the scan, the TMs keep on monitoring the PT, while the TL is free to speak to the OR, the neurosurgeon, and the laboratory to have the blood results. 

Review & Tips

Let’s rapidly review how the primary survey has been conducted in this two different scenarios:

  • First team: the primary survey has been conducted as the ATLS straight line (A → B → C → D → E) and the decision-making process has been held by the TL alone. The TL has also to make contacts with the other specialists and services the PT may need.
  • Second team: the primary survey has been squeezed in a horizontal line (A+D, B, C → E). The procedures have been done by the TMs, as they could, according to the findings and the experience they have. The TL has the time to analyze every step the TMs have done, and he is free to help anyone if needed. Moreover, the TL has the time to collect and give information from and to the specialists, while the TMs guard the PT.

The second method, the real team approach, looks fabulous, but it is full of pitfalls!

Working in a team may be already stressful in a quiet setting due to conflicts among TMs or to difficulties in communication. Now, if you try to bring this situation in a stressful trauma resuscitation bay, you can only start to imagine the chaos and the risks you may find yourself in. This is especially true if you are not used to managing trauma cases, or if you keep on changing the members of the team every time. 

Reading these lines, you should have noticed two different types of leaders (with completely different skills), and two different types of leadership you may need to approach the patient. Moreover, you have to consider the setting you’re in (do you have experienced colleagues, or are you the only one with trauma knowledge?). Be ready to adapt your team and yourself based on the resources you have. You don’t have to use each available person if you don’t need them… Sometimes less is more!

On purpose, we have not mentioned specialties along with the team roles. They should not be assigned by their specialty (doctors and nurses, surgeon or anesthetist or EM doctor), but on their real abilities.

Here there are some tips we have learned (from experienced colleagues, courses, or personal mistakes) and sometimes still struggle to do:

  • Use wisely the time you have before the PT arrives (see preparedness);
  • Prepare the team, give roles to the TMs, and remember them what to do;
  • Start thinking about what may happen according to the information you have, and start to create a resuscitative pathway;
  • Be ready to embrace the plan B, if plan A is not working;
  • Have a plan B… and a plan C, D, E, and so on!
  • Listen to your TMs suggestions;
  • If you’re a TM, give suggestions to your TL (don’t overcome the TL);
  • Make sure team communication is circularly closed (say the name of whom you’re speaking to, make eye contact, make him repeat what to do, make sure to have feedbacks when things are done);
  • Regularly stop for few seconds to recap what you know so far and what to do, especially when you feel overcome by the situation (better to lose 30 seconds to properly understand what is going on than to lose a patient during a CT scan because you misinterpreted his hemodynamic status in the trauma bay);
  • Slow is smooth, smooth is fast!

To get to the point, if you’re lucky enough to have a team, train with them and create a real squad!

See you next time… Namasté!

References
  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Peitzman AB, et al. The Trauma Manual: trauma and acute care surgery; 4th Ed. Philadelphia, PA: Lippincott; 2013.
  3. European resuscitation Council and European Society for Trauma and Emergency Surgery. European Trauma Course: the team approach.
How to Cite This Post

Marrano E, Bellio G. The Trauma Team Management. Surgical Pizza. Published on September 9, 2020. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/trauma/trauma-team-management/].

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