Tuesday, October 25, 2016

Team Organization in Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation

Team Organization in Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation
           Earlier in 2016, COL Robert B. Lim, MD, U.S. Army, edited a landmark text Surgery during natural disasters, combat, terrorist attacks, and crisis situation. I had the opportunity to chat with Dr. Lim about his text. Having been deployed numerous times into the zone of combat, I believe he can be considered an expert in this area. Several chapters peaked my interest (especially the one on unexplored ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation" interested me most due to the details provided on trauma teamwork in the combat environment. Trauma teamwork is difficult enough under normal circumstances, but just imagine managing a team in remote or hostile environments.
           In their chapter Jones and Wisbach reinforce the need for strict organization and planning. There is no room for error. They reiterate that success starts with Mass Casualty Planning and Rehearsal. After arrival to the operational area the team should discuss and rehearse the casualty plan. Preparation includes memorizing the layout of the trauma area, the facility as well as the outlying areas. Defined team positions and roles are key to avoid confusion and delays. In spite of the appearance of redundancy, prior to each incoming casualty, stating names and roles avoids confusion. Continued repetition focuses the team and reminds the team about potentially forgotten measures (PPE, civil closed loop communication). Team member names should be readily visible on each member to assure communication is clear and avoid distractions. Supplies and equipment need to be in standardized placement close to the immediate resuscitation area to avoid excess noise in asking or searching for supplies.  Each team member has an assigned checklist posted at their work station (detailed summary of those checklists noted in their chapter). The trauma team leader (TTL) should stand in a routine position where they have continued observation of the team (i.e. Foot of bed). One examiner is then on one side of the patient and the other examiner or RN on the other. Anesthesia should be at the head of the bed. Prior to patient arrival, each member needs to confirm their checklist has been reviewed. Team review should remind the team that only the TTL should be providing resuscitation instructions thereby avoiding the confusion that results from too many members instructing the team. A hierarchal structure helps to maintain the TTL's situational awareness. The TTL needs to remember to take a pause for summarization prior to and after critical steps in the resuscitation process- preintubation, post-BP stabilization- to avoid missing crucial details. The authors remind us that in spite of combat casualties occurring in austere environments, following standard clinical practice guidelines (CPG's) is vital- just because you may be remote, standard evidence-based protocols avoid conflict and improve team dynamics. Several other reminders of TTL roles are highlighted in this chapter.
              Finally the authors remind us of three vital team leadership roles- 1. watch for and control team stress and conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development (forming, storming, norm ing, performing, and adjourning) to assure your team is developing appropriately 3. Morale retention and support from "compassion fatigue" is necessary to survive the arduous often primitive conditions.

I immediately had a few questions for the authors and when I met up with Gordon Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he agreed to discuss these.
When you first went into action, what preconceived notions were instantly proven false?
When you arrived at a designation, was there anything that totally caught you by surprise?
Describe the most remote, austere operating environment you faced? Any take homes from that experience?
Was there any aspect of team leadership you predetermined you would be adept at but found needed improvement, or a total rehaul?
Any leadership aspect you had not considered or discounted that you found you had to learn on the fly?
When the teams form initially, do the members automatically register this concise preformed process or does the process not always work as well as you wished?
How do you quiet the room when the commotion becomes distracting? Paul Lucha ret. told me he just keeps turning his voice decibels quieter and quieter until everyone has calmed down.
If a team member attempts to take control but is clearly wrong, how do you redirect them?
Any particular lesson learned about combat care you did not expect but sticks with you today?
Have you arrived at a treatment facility and just did not have time for orientation and rehearsals?
Have you missed something that in looking back was obvious?
Did you ever receive a godsend help when you were praying for it that arrived from a source you least expected it?
When you first started, what technique worked best for you in controlling your anxiety? What about controlling another's anxiety? Or maybe you never had a situation that did not pose a threat and therefore was not anxiety provoking?
When you encounter a patient who has no chance for survival but clearly has their mental faculties totally intact what does one say to them?

Lim RB. Surgery during natural disasters, combat, terrorist attacks, and crisis situations. New York. springer. 2016.

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