Throughout my career, I’ve always had a keen interest in trauma. As I prepare to depart to take up a trauma fellowship at the Alfred hospital in Melbourne, I was interviewed for the case report podcast and asked for some of my ‘tips and tricks’ of the trauma care trade. When I started to prepare for that talk and now this blog post, I thought, what would I like to have known when I started off receiving major trauma patients? What advice would I give to my more junior self?
“Professionals prepare properly”. That phrase that I first heard from friend/colleague/mentor Dr Cian McDermott (@cianmcdermott) is still ringing in my ears. We need to prepare now for that patient that we might meet on shift later on today, perhaps tomorrow or maybe even years into the future. If preparation is key, then I feel that the ‘zero-point survey’ from Cliff Reid et al. is a great place to start. It represents somewhat of a change to the traditional teaching that we are all familiar with such as ATLS (Advanced Trauma Life Support) in that it asks you to prepare to receive the patient before the point of first patient contact. It asks you to ready yourself, your team, your environment, and your system. So here are some of my hopefully helpful hints, framed around the survey.
Me, myself and I
Is it just me or does a major trauma pre-alert bring about the flight before the fight response? How often does a team member come to you and their first contribution is… do I have time to run quickly to the toilet? They do. You do. Always. Manage your own stress.
Tip 1: Take 30 seconds for yourself
When I am the Trauma Team Lead (TTL) preparing to receive a patient, I often walk the long way around to the resus room. This may seem strange when time is of the essence, but it affords me that thirty seconds of headspace for a quick personal pep/prep-talk. It allows me to clear my mind, focus on the task at hand, formulate a plan, rationalise my ‘fight-flight’ response that will allow me to optimise my ability and to meet the patient on the correct side of the Yerkes-Dobson curve. When a patient is at their worst, they demand your best!
Tip 2: Acknowledge your weakness and then address it
As trainees, at the end of each year, we are asked to fill out an end of year assessment for ourselves and our training sites. The questions are straightforward until, question four. List your weaknesses.
This can sometimes be hard, not because we are perfect (far from it), but because we often either do not acknowledge our weaknesses or indeed somewhat suppress them. We need to look critically at ourselves, to find our weaknesses and then, to address them. For me, as a junior trainee, I felt that I needed to improve my airway skills, so I attended the TEAM course. I wanted to enhance my critical care management, so I attended the ED-Critical care course in Ede, Netherlands with Cliff Reid. Are you confident with the advanced resuscitation skills that are required in trauma? Could you perform a lateral canthotomy, pericardiocentesis or thoracotomy? If not, find a course (shameless plug www.resuscitate.ie)!
Trauma is a team sport
Emergency Medicine is far better than General Surgery (cue onslaught)! To qualify this, I started life as a basic surgical trainee before transitioning to Emergency Medicine and for me, my work-life balance instantly became better! There were many reasons for this.
- I no longer had a bleep
- I only had to be in one place at one time (albeit often that means being thinly spread over a large department). And most importantly…
- My team were always with me (onsite).
I am passionate about Trauma Teams (TTs) as they have been shown to optimise patient care by reducing time to diagnostics and interventions. In Ireland, there are currently no accepted TT configuration or activation criteria for such a team. This presents a massive challenge in terms of data capture with only 8% of major trauma patients documented as being met by a trauma team on arrival. I have recently written a position paper for IAEM (Irish Association for Emergency Medicine) and the Emergency Medicine Programme (EMP) on TTs that can be used for collaborative engagement with the National Trauma Office as well as to engage with the key stakeholders including Surgery, Critical Care, Trauma & Orthopaedic Surgery and nursing amongst others to aid the development and roll-out of TTs for Ireland so, watch this space!
Back to the survey. Prepare the team. As the TTL; assess the pre-alert (remembering Mansoor Khan’s wise words that in major trauma, “the word stable only refers to the place where a horse lives”), activate the appropriate team, allocate appropriate roles, and anticipate what this resus may entail.
Tip 3. In expecting the unexpected, set out a shared plan.
What is the best-case scenario? What is the worst-case scenario? Create a shared mental model with the team. If a thoracotomy is required then having anticipated this prior to the patient’s arrival might alleviate some of the fear factor. If a team member is not comfortable witnessing such a resuscitation, then it allows them to excuse themselves at an earlier stage.
Tip 4. Insist on a silent resuscitation
Noise suggests chaos. It may indeed be the pen perfect resuscitation, but if people have to raise their voice and even shout to be heard, this can often be disruptive.
Is the environment ready? Is there sufficient space to receive the trauma? If anticipating a Code Red (massive transfusion), could two resus bays be made available? Is there a dedicated trauma bay? If not, can one be established?
Tip 5. Better to be looking at it than looking for it
Check and re-check equipment. Are there blood products in the fridge? Have the rapid infusers been primed and readied? Is there any additional equipment that is likely to be required such as good trauma shears (preferably ones with no plaster of Paris on it!), pelvic binder, good haemostats (not Kaltostat), bite blocks etc. If the equipment that you require is not available, where can you get it from? Can you improvise? Two quick tips; CAT (Combat Application Tourniquet) MIA? Use a manual blood pressure cuff. No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).
If the equipment is there, then use it. When it comes to POCUS, you may not be using E-FAST, but, in a major trauma patient with complex facial fractures, marking the CTM (cricothyroid membrane) ultrasonographically informs the team that surgical cricothyroidotomy is a potential. Pre-empting the requirement for life, limb and sight-saving procedures and discussing them out loud, as a group in advance will go a long way to help avoid decision paralysis.
A Trauma System for Ireland? Hopefully.
We can start today by ensuring that our own house is in order. How do we do this? Teach. Train. Simulate. MDT simulation in your resus room allows new processes to be vetted and existing systems tested. Logistics are far more difficult to test in simulation labs. Practice where we preach. Can processes be streamlined? Can default trauma identifications be used? Does the trauma call generate the same response as your STEMI or FAST call? Out-of-hours are trauma calls consultant-led? If not, can telemedicine be used for offsite support?
Tip 6. TRAUMA CALL = STEMI CALL = FAST CALL
Are there checklists out there that will allow trauma care delivery in a safer manner? Trauma proformas allow accurate and efficient documentation and also serve to prompt the delivery of time-critical actions.
Multidisciplinary teaching is key. Having a regular trauma forum to discuss the major trauma cases that have attended is crucial. Too often the only forum that these cases are openly discussed is in some Morbidity and Mortality meeting when there has been a bad, or at least unexpected outcome? Do we discuss the ‘good’ cases? Do we hot and cold debrief? Have we Schwartz rounds in our institution?
Nobody will forget 2020 in a hurry. COVID-19 has had a profound impact on each of us. Has it all been bad? I suggest not. Staff numbers have increased (perhaps not as good as they were in May, but certainly an improvement). Emergency Departments have increased in size. Equipment that was on an exceptionally long wish list has suddenly appeared. With this newfound political resource and energy, healthcare has by-in-large, improved (or maybe it is just less bad). With this in mind, trauma care in Ireland is set to undergo reconfiguration with the development of an inclusive System and based on similar international systems, destined to save lives. The political standstill that marred healthcare might be changing. Trauma Care delivery is changing. The Southern and Central trauma leads for Ireland have recently been appointed. With very tightly crossed fingers and a few more grey hairs for the Clinical Lead for Trauma Mr Keith Synnott, a trauma system for Ireland seems to be on the horizon.
Lastly, the handover from your pre-hospital colleagues.
Final tip. Before taking handover, ask three important questions
– Does the patient have any exsanguinating haemorrhage?
– Do they have a central pulse?
– Are they protecting their airway? If so, carry on with the patient transfer.
Sometimes in my career, I have felt like the proverbial rabbit in headlights, nodding in seeming agreement with my paramedic colleague but occasionally with little information being retained. Nowadays, I try to summarise the handover in a one-sentence synopsis. This helps me to focus and hopefully the team to do likewise. Always ask for silence and sterility for handover. It only takes 30 seconds and may save much more than this if there is a missed communication piece.
1. Reid C, Peter Brindley P, Hicks C, Carley S, Richmond C, Lauria M, and Weingart S. Zero pointsurvey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med;Sept (5(3)):