Here is the write-up of our latest in situ sim. Along with the human factors feedback from our colleagues in aviation (which you can find at the end of the post), I’ve included the “technical” feedback from myself and two of my EM consultant colleagues as I thought it might be of interest.
Young male, cyclist v car just outside hospital, ambulance scooped and ran (and therefore brought to us… not a MTC).
A: snoring, vomitus around mouth
B: external signs of right sided chest trauma, hypoxic, dull and decreased AE right
C: tachycardic and becoming increasingly hypotensive
D: GCS7, tolerating OPA, bleeding from back of head indicating head injury
A: at risk due to low GCS
B: evidence of massive haemothorax (confirmed by EFAST)
C: Severe shock, likely hypovoloaemic due to massive haemothorax +/- other massive blood loss.
It was our most ambitious sim so far. A REAL trauma call was put out and attended by anaesthetics and surgery. A REAL major haemorrhage was put out with blood initial blood products retrieved and delivered. I would first like to take this opportunity to thank everyone involved. Particular thanks to our specialty colleagues whose presence made for a truly authentic learning experience.
There was so much going on in this sim. Loads of examples of good practice. Loads of learning points.
It was easy to forget a CT1 (i.e. fairly junior trainee) was team leader. Dan Worley performed beyond his years of experience and did the department proud. He was calm, systematic and made sound clinical decisions throughout.
Dan had a very competent team to work with and delegated tasks clearly and appropriately.
All key interventions were achieved: RSI, right intercostal drain, major haemorrhage protocol activated and blood products given.
A pelvic binder was fitted. This was entirely appropriate in this case.
This moment is key. It might be the only opportunity to learn what actually happened to the patient and it is too often lost in the chaos. In this sim it could have been better listened to by the whole team.
Once the patient has been transferred onto a resus bed, the team leader must demand silence and direct everyone’s attention to the paramedic handing over.
A haemothorax was identified early in the resuscitation. The drain was placed by surgical registrar with good technique and sterile precautions. However, it took more than 15 minutes to perform the procedure start to finish.
Rapidly performing this procedure is crucial because:
- Re-expanding lung may tamponade the bleeding vessels.
- Need to determine if it is a massive haemothorax (blood loss of >1,500 mL upon drain insertion, or blood loss of >200 mL/hr over 2-4 hours post drain) – if so, resuscitative thoracotomy indicated.
A challenge-response checklist pre-RSI is crucial for patient safety. This must be completed by the intubation team (usually anaesthetics) before every RSI in resus. Ultimately, it is the team leader’s responsibility to ensure it is done.
Cardiac arrest (2222) call
This was put out when the patient’s clinical course further deteriorated towards the end of the sim (but prior to the chest drain insertion I believe… though I might be wrong there).
A medical cardiac arrest team will not be helpful in a traumatic cardiac arrest. In fact they are likely to confuse proceedings as they will have an “ALS mindset”. I won’t go in to detail here re: TCA (that’s for a future sim). For now check out this document.
Dr. Nora Brennan feedback (EM Consultant)
This patient is extremely sick and will likely proceed to cardiac arrest if not resuscitated rapidly. This is time critical and the type of patient for whom we coined the term ‘golden hour’. Priorities:
- Identifying and stopping the bleeding, damage control resuscitation.
- Immediate tranexamic acid (CRASH 2 trial – benefit if given within 3 hours, most benefit if within hour 1).
- Resuscitate with blood + blood products to maintain pulses/cerebration. Do not to chase a ‘normal’ BP.
- Early plan for definitive airway but be aware that on induction, BP likely to crash – avoid need for ‘rescue ionotropes’ by ensuring you have already started to fill the patient (see above)
- Anticipate likely clinical course – can the patient be managed here or will they need to move to MTC – what essential interventions are needed before transfer?
Dr. Rachel Landau feedback (EM Consultant)
From the outset, if you are assessing a patient who likely has multi-system injuries, need to consider whether their care needs exceed the capability of the Trauma Unit and they need transfer to the MTC. If initially this is thought unlikely, keep in mind your decision might change as injuries are identified.
Keep the arrival of other team members in mind. If they have not arrived make sure they are chased up to attend as you may need them. Similarly when you notice they have arrived engage them by finding out their name and role and make sure they are updated to what is going on.
The person initially tasked with documenting was redirected to another task quite early on. If at all possible there should be a scribe throughout recording key events on the timeline. This documentation is vital as a contemporaneous clinical record and also vital if the patient is being transferred.
Check any blood product before commencing transfusion.
If a procedure such an an ICC is being performed the clinician doing the procedure must satisfy themselves that they are putting the drain into the correct side. They should not rely on someone else telling them which side it is.
Intubating a trauma victim who is periarrest from hypovolaemia is a dangerous time. Great care should be taken with choice of drugs used to ensure the induction does not precipitate a cardiac arrest.
Human factors feedback from Captain Dave Fielding, Captain Alex Jolly and First Officer Russell McDonald
Good afternoon Robbie,
A huge thank you for having us in the sim once again. What a tremendous atmosphere in resus, reinforcing how much traction this exciting human factors collaboration is gaining. Today, myself and Dave were joined by another Project Wingman, First Officer Russell McDonald. The extra crew member was fitting as a lot of what we saw today highlighted the importance of how you utilise your additional crew in high workload events.
Firstly, congratulations to the entire team. Today’s scenario involved the arrival of a severely injured trauma patient as a result of an RTA, the stakes were high! The clinical lead was relatively junior compared to our previous observations and was supported by experienced staff from anaesthetics, surgery, and A&E. I think today was also a crucial moment in our HF feedback processes as it highlighted the importance of how we divide our attention within the room. This trauma was far more complex than simply a leader and their team, it was a synergy of different specialities all demonstrating their own forms of leadership and followership. How we accurately capture this in future observations will be subject to group discussion over the coming days I’m sure.
As per our previous sim observations, we have categorised the feedback into Workload Management, Communication, Situational Awareness, and Problem Solving/Decision Making, finishing with a couple of take-home points.
Workload management & comms
A trauma call was announced and the lead was called to resus. Suddenly, we had a room of staff from different departments with very little information on the inbound patient. This reminded us of flight crew at the start of a days work. We go to a briefing room, we probably don’t know most of the cabin crew, and there is a good chance we haven’t flown with the First Officer. What will the day entail? What do you want from your team? As a Captain, you want them to know that you value their input, they will be your eyes behind the closed flight deck door, and you want your First Officer to feel that they can speak up and correct your actions if you make a mistake. This is what we call the ‘golden 5 minutes’. Rally the troops because when the workload increases, you won’t have time to convey your command style.
The lead had a brilliantly calm approach throughout the sim, used first names, and managed multiple interruptions extremely well, prioritising “patient not paperwork” when the situation deteriorated. This was excellent prioritisation – in aviation you have focused on the safe flight of the aircraft before moving onto the navigation and the communication i.e. Aviate, Navigate, Communicate (ANC). Distribution of tasks is essential during a high workload. Try to concentrate on the bigger picture – there was one occasion where the lead could have delegated the ABCDE, meaning he would have been more aware of his surroundings and spotted the arrival of the blood bank sooner.
The lead anticipated workload peaks brilliantly which led to some quiet periods within the simulation. Importantly, the silence was respected and allowed specialists to focus on tasks (chest drain, intubation) this was very much like a sterile cockpit (conversation to a minimum below safe altitudes). Communication was clear although during the handover some of your colleagues were quite noisy. “Attention, crew at stations!” is an alert call we use to make the entire crew stop what they’re doing and become evacuation/emergency procedure focused – “I am the lead, everybody please listen!” would be a great equivalent. Every team member did listen actively, potential ambiguities were brilliantly avoided when the lead clearly pointed the side of the chest the surgeon was to drain – in flight we always point and cross confirm fuel pumps and guarded switches before selection.
One potential threat that we have noticed in every sim is a lack of read-back – in this case, when requesting 1mg of TXA, there was no confirmation. We can’t stress enough how safety critical a read-back is in aviation, perhaps consider this part of your ‘golden 5 minutes’ as a reminder?
We were impressed with the level of open communication carried out by all team members, nobody talked over each other and people were comfortable with expressing concern. There were lots of mini reviews carried out by the lead which was a great way to keep the SA level high. It would have been nice to hear open questions “what is the most critical issue with the patient right now?” or use the severity scale with each specialist to establish the most pressing issue (pneumothorax/bleeding). With some very experienced surgeons and anaesthetists in the room, perhaps there was something you may have missed? Ask team members not only what needs doing but how. Sharing mental models ensures you don’t find yourself micromanaging e.g. “Tell me how you plan to fly this approach?”.
Problem solving/Decision making
It was clear this simulation went very well from a technical perspective. We would like to have seen more pressure testing of the diagnosis e.g. “Tell me why this isn’t a massive right side trauma?”. At one point the lead asked “what are our options?” but then answered their own question, give yourself time to get a different perspective as you may have missed something.
With more complicated failures in flight, we try to use an acronym to assist in the decision making process. Perhaps think of an acronym to help you with time, diagnosis, treatment options, assignment of tasks, and review. If you can maintain a consistent structure during emergencies, even complex events will feel entirely manageable.
Take home points
– Use the ‘golden 5 minutes’ to empower team members around you and clarify roles.
– Read-backs/closed loop communication is essential during safety critical tasks.
– Pressure test your decision making, try to disprove your diagnosis by asking your team members if you have missed anything.
Another awesome job guys. Through evidence-based training (EBT), we will start to highlight trends in key areas, discuss some aviation-related examples, and hopefully reinforce good practices.