Trauma Team Dynamics (eBook)

Lawrence M. Gillman, MD MMedEd FRCSC            Department of SurgeryUniversity of ManitobaWinnipeg, Canada  Sandy Widder, MD FRCSC FACS MHA MSc QIPSDepartment of SurgeryUniversity of AlbertaEdmonton, Canada  Michael Blaivas, MDProfessor of MedicineSchool of MedicineUniversity of South CarolinaColumbia, SC   USADepartment of Emergency Medicine  St. Francis HospitalColumbus, GA   USA  Dimitrios Karakitsos MD PhD DScDepartment of Internal MedicineUniversity of South Carolina, School of MedicineColumbia, SC   USADivision of Critical Care, Department of AnesthesiologyKeck School of MedicineUniversity of Southern CaliforniaLos Angeles, CA   USA

Dedication 6
Foreword 8
Preface: Trauma as a Team Sport 10
Contents 12
Contributors 16
Part I: Trauma Team Preparation 20
1: The Genesis of Crew Resource Management: The NASA Experience 21
Humble Beginnings 21
A New Paradigm Is Born 22
Key Points 24
References 24
2: Crisis Resource Management Training in Trauma 26
Introduction 26
The Case for CRM: Origins of Team Training in Aviation 26
CRM in Medicine: Principles, Limitations, and Frontiers 28
Human Factors in Trauma Care 29
Key Points 29
References 29
3: Leadership Theories, Skills, and Application 31
Background 31
Understanding Good Leadership 31
Qualities of a Good Leader 32
Strategies to Improve Leadership 33
Conclusions 34
Key Points 34
References 34
4: Teamwork and Communication in Trauma 36
Introduction: Why Does Teamwork Matter? 36
What Does It Take to Create a Team? 36
Teamwork: Good and Bad 37
Team Leadership 101: The Shared Mental Model 37
Say What You Mean and Mean What You Say 38
Crisis Communication 101 38
Conclusions 40
Key Points 40
References 40
5: Situational Awareness and Human Performance in Trauma 42
Introduction 42
Situational Awareness 42
Situational Awareness: Level 1 42
Situational Awareness: Level 2 43
Situational Awareness: Level 3 44
Factors Affecting Awareness and Performance 44
Attention 44
Stress 45
Conclusions 46
Key Points 46
References 46
Part II: Trauma Team Design 47
6: Paramedical and Nonmedical Personnel 48
Introduction 48
Key Points 51
References 51
7: Transport Medicine 52
Introduction 52
Patient Considerations 55
Adequate Patient Preparation for Transport 55
Airway with C-Spine Control 55
Breathing 55
Circulation 55
Disability 56
Exposure 56
Patient Monitoring and Ongoing Resuscitation 56
Seamless Transition onto Receiving Medical Teams and Comprehensive Handover Procedures 56
Aeromedical Transport 57
Boyle’s Law (P ? 1/V) 57
Dalton’s Law (Total = Pressure 1 + Pressure 2 + … Pressure n) 57
Universal Gas Law (PV = nRT) 57
Conclusions 58
Key Points 58
References 58
8: Trauma Team Structure and Organization 59
Introduction 59
Team Members and Roles 60
Trauma Team Leader (TTL) 60
Anesthesiology 61
Emergency Medicine Physician 61
Respiratory Therapy 61
General Surgery 61
Orthopedic Surgery 62
Neurosurgery 62
Circulating Nurses 62
Recording Nurses 62
Trauma Team Activation 62
The Trauma Bay 63
Trauma Team Function 63
Conclusions 64
Key Points 65
References 65
9: Interprofessional Trauma Team Roles 67
Introduction 67
Leadership 67
Nursing Roles 68
Respiratory Therapist Roles 69
Interdependence of Task Work 71
Conclusions 72
Key Points 72
References 72
10: The Trauma Bay Environment 73
Introduction 73
General Design of a Trauma Resuscitation Area 73
Access to the Resuscitation Area 73
Patient Flow and Disposition 74
Surge Capacity 74
Decontamination 75
Communication 75
Control Center 75
Security Considerations 75
The Trauma Bay 75
Trauma Observation Unit Setup 76
Special Situations 77
Noise Discipline in Trauma Resuscitation 77
Resuscitation in the Operating Room 77
Hybrid Operating Rooms 77
Conclusions 78
Key Points 78
References 78
11: Quality Improvement and Trauma Quality Indicators 79
Introduction 79
Healthcare Quality and Relevance to Trauma 79
Quality Indicators in Trauma 80
Quality Improvement 82
Opportunities for Improvement 83
Key Points 83
References 83
12: Putting It All Together: Quality Control in Trauma Team Training 85
Introduction 85
Defining Quality in the Team Context 85
The Military-Medical Overlap: Some Quality Control Principles in Trauma Teams 86
Individual Qualifications and Team Training 87
Team-Based Principles 87
Other Factors Affecting Team Performance 88
Continuous Improvement Processes 89
Conclusion 89
Key Points 89
References 90
Part III: Trauma Resuscitation 91
13: Trauma Resuscitation 92
Epidemiology of Trauma 92
Death Due To Injury 92
Mechanisms 92
Trauma Teams and Preparation 93
Assessment and Priorities: ABCDE 93
Airway 95
Breathing: Oxygenation and Ventilation 96
Circulation: Recognition of Shock and Control of Hemorrhage 97
Neurologic Injury 98
Musculoskeletal Trauma Including Spine 98
Conclusions 99
Key Points 99
References 99
14: Damage Control Resuscitation 101
Introduction 101
Massive Transfusion 101
Permissive Hypotension 102
Damage Control Surgery and Its Indications 103
Vascular Damage Control Techniques 104
Abdominal Compartment Syndrome 105
Open Abdominal Management 105
Key Points 106
References 106
15: Damage Control: From Principles to Practice 109
Introduction 109
Indications for Damage Control Surgery 109
Ground Zero: Scene to Emergency Department 110
Damage Control Part 1: Operative Intervention 112
Damage Control Part 2: Resuscitation 113
Damage Control Part 3: Definitive Repair 113
Damage Control Strategy Under Special Circumstances 114
Blast Injuries 114
Burns 114
Head Injury 115
Crush Injury 116
Conclusions 117
Key Points 117
References 117
16: Trauma Team Decision-Making 119
Introduction: A Well-Planned Journey into the Unknown 119
The First Principles of Trauma Resuscitation 119
Early Data Acquisition: The Primary Survey as a Decision-Making Tool 120
Weighing the Options 121
The Anatomy and Physiology of a Decision 124
Clinical Practice Guidelines (CPGs) 125
Trauma Team Leadership: Translating Decisions to Action 126
Forward Communication and Handover 127
Special Considerations in Mass-Casualty Situations 127
Future Directions: The Role of Information Technology 127
Conclusions 128
Key Points 128
References 128
17: Emergency Critical Care Procedures 130
Introduction 130
Emergency Procedures and Team Dynamics 130
Airway Management 130
Tube Thoracostomy 131
Controversies 132
Antibiotics 132
Tube Selection 132
Occult Pneumothorax 132
Complications and Post-tube Thoracostomy Management 132
Vascular Access 133
Peripheral Intravenous Access 133
Central Intravenous Access 133
Intraosseous Access 135
Ultrasound 135
Resuscitative Thoracotomy 135
Outcomes 136
Contraindications 136
Volume Expansion 136
Management 136
Diagnostic Peritoneal Lavage 137
Interpretation of Results 137
Conclusions 137
Key Points 137
References 137
Part IV: Specialized Trauma Populations 140
18: Trauma in the Pediatric Patient 141
Introduction 141
Pediatric Trauma Particularities 141
Airway Considerations 142
Head and Spinal Trauma 142
Torso Trauma 142
Psychosocial Considerations 142
Pediatric Management Challenges 142
“Critical” Ultrasound in the Pediatric Patient 145
Pediatric Trauma Team Composition and Dynamics 147
Conclusions 149
Key Points 149
References 149
19: Trauma in Pregnancy 152
Introduction 152
Physiologic Changes of Pregnancy 152
Shock in the Pregnant Patient 153
Distinct Aspects of the Pregnant Trauma Patient 153
Fetal Monitoring 156
Radiology 156
Perimortem Cesarean Delivery in Trauma 158
Coordination of Specialties in the Trauma Bay 159
Conclusions 159
Key Points 159
References 160
20: Medical Comorbidities and Trauma 163
Introduction 163
Pre-injury Phase 164
Chronic Alcohol and Drug Use 164
Suicide Risk 164
Driving Risks 164
Fall Risks 164
Injury Phase 165
Surgical Management Strategies of Severe Injury 165
Recovery Phase 166
Outcomes After Injury 166
Fractures and Mortality 166
Delayed Complications and Mortality 166
Futile Care 167
Frailty 167
Conclusions 167
Key Points 168
References 168
Part V: Emergency Ultrasound and Trauma Imaging 170
21: Basic Trauma Ultrasound 171
Introduction 171
The FAST Examination 171
Technique 171
Pericardial View 172
RUQ View 172
LUQ View 173
Pelvic View 174
Uses 175
Blunt Abdominal Trauma 175
Penetrating Trauma 175
Limitations 176
Conclusions 177
Key Points 177
References 177
22: Trauma Ultrasound: Beyond the FAST Examination 179
Introduction 179
Trauma Ultrasound Development 179
The Fast Examination in Critical Review 180
Ultrasound Equipment and Settings 180
Additional Ultrasound Applications in Trauma 180
Additional Equipment and Views 180
Pleural Effusion 180
Pneumothorax 181
Resuscitation and Volume Status 183
Musculoskeletal Ultrasound 183
Head Trauma 185
Contrast-Enhanced Ultrasound 186
Future Directions in Trauma Ultrasound 186
Conclusions 187
Key Points 187
References 187
23: Telemedicine and Future Innovations 190
Introduction: The Need 190
The Promise of Innovation and Telemedicine 190
History and Development 191
Outcomes 192
Developing a Telemedicine System 193
The Future 193
Key Points 194
References 195
24: Imaging in the Stable Trauma Patient 196
Introduction 196
Imaging Modalities 196
Plain X-Ray 196
Focused Assessment with Sonography for Trauma (FAST) 198
CT Scan 198
Other Modalities 199
Critical Thinking 200
Key Points 201
References 201
Part VI: Tactical Emergency and Disaster Medicine 203
25: Disaster Medicine 204
Introduction 204
Natural or Man-Made Disaster 204
The Disaster’s Cycle 205
Incident Command System 206
Triage 207
“Second Hit” Phenomenon 207
Key Points 208
References 208
26: The Multi-casualty Trauma 209
Introduction 209
Historical Perspective 209
Ethical Issues in Multiple Casualty Trauma 209
Prehospital Management 210
Triage 210
“START” System for Triage 211
Pediatric Considerations 212
Patient Transportation and Allocation Within the Trauma System 213
Intrahospital Management 213
Transfer Corridors 214
Blood Bank 214
Staff-Recalling Systems 214
Intensivists and Anesthesiologists 214
Training, Simulations and Preparing for MCT 215
Debriefing 215
Conclusions 215
Key Points 215
References 216
27: Critical Incident Team Dynamics and Logistics 217
Introduction 217
Crew Resource Management (CRM) 217
Characteristics of Crises 218
Key Elements of Team Dynamics 218
Command and Control 218
Command and Control Architecture 219
Resources 219
Review Process Including Logistics 219
Transactive Memory 220
Life Cycle of Teams 220
Team Building (Before) 221
Team Performance (During) 221
Team Debrief (After) 222
Stressors to Be Managed (Fig. 27.5) 222
Health 222
Fitness 222
Sleep Deprivation and Fatigue 223
Home and Family 223
Alcohol, Illicit Substances, and Mental Health 223
Stress and the Pyramid of Complexity 223
Interagency Collaboration 224
Bystanders 224
Emergency Medical Services/Tactical EMS 224
Conclusions 225
Key Points 225
References 225
28: Terrorism and Urban Trauma 227
Introduction 227
Forms of Terrorism and Urban Trauma 227
Injuries and Injury Patterns 228
Paradigm Shifts in Terrorism 229
Changes in Emergency Medical Systems Structure 229
Improved Community Preparedness 230
Conclusions 231
Key Points 231
References 231
29: Tactical Emergency Medicine, Procedures, and Point-of-Care Evaluation in Austere Environments 233
Introduction 233
Austere and Tactical Environment Emergency Medicine 233
Equipment for the Tactical and Austere Environment 234
Procedures 235
Assessment and Testing 235
Conclusions 236
Key Points 236
References 236
30: Trauma in Austere Environments: Cold Injuries and Hypothermia 237
Introduction 237
Classification 237
Hypothermia 237
Pathophysiology of Hypothermia 237
Systemic Manifestations of Hypothermia 238
Cold Injuries 238
Pathophysiology of Cold Injuries 238
Freezing Cold Injury 238
Nonfreezing Cold Injury 239
Management 239
Key Points 240
References 240
31: War Zones and Biological Warfare 242
Introduction 242
War Zones 242
Biological Warfare 243
Conclusions 245
Key Notes 245
References 245
32: Nuclear Injuries 247
Introduction 247
Historical Background 247
Physics of Weaponry 247
Initial Blast Injuries 248
Thermal Effects 248
Radiation 248
Medical Management of Nuclear Device Related Injuries: Scene Considerations 248
External Radiation Hazard 249
Internal Radiation Hazard 249
Transportation 249
Hospital Care 249
Conclusions 250
Key Points 250
Outline Placeholder 250
References 250
Further Reading 250
33: Trauma and Surgical Capabilities for Space Exploration 251
Introduction 251
Physiological Challenges in Spaceflight 252
Historical Perspective 253
Parabolic Testing 254
Surgical Field Testing 256
Surgical and Advanced Life Support Procedures 256
Surgical Procedures in Space 258
Diagnostics 259
Trauma Care in Space 259
Immediate Damage Control Procedures 260
Crew Medical Officers 261
Conclusions 261
Key Points 261
References 261
Part VII: Trauma Team Education 265
34: Designing a Simulation Curriculum 266
Needs Assessment 266
Learning Objectives 267
Instructional Methods 269
Simulation for Assessing Learners 270
Program Evaluation 270
Conclusions 270
Key Points 270
References 271
35: Designing Multidisciplinary Simulations 272
Introduction 272
Background 272
Simulation 101: General Principles 272
Physical Fidelity 273
Functional Fidelity 273
Psychological Fidelity 273
Overcoming Obstacles to Simulation 274
Simulation 201: Basics of Scenario Development 276
Choosing a Clinical Stem and Scripting the Scenario 277
Simulation 301: Novel Additions to Simulation 277
Maximizing Simulation Scenarios 277
Telephone Simulations 278
Handover Simulation 278
System-1 Versus System-2 Simulation 278
Blindfolded Simulation 278
A Few Notes on Confederates 278
Creating True Multidisciplinary Simulation Scenarios 279
Developing Scenarios with a Multidisciplinary Team of Authors 279
Creating Discipline-Specific Objectives and Discipline-Specific Tasks 279
Staged Entry Scenarios 279
Distance Resuscitations 279
Measuring the Impact of Simulation 279
Conclusions 279
Key Points 280
References 280
36: Constructive Debriefing for Trauma Team Education 281
Introduction 281
Debriefing Structure and Method 281
Debriefing Structure 281
Debriefing Method 282
Advocacy Inquiry 283
Plus Delta 283
Directive Feedback 283
Blended Methods 283
Debriefing Real Trauma Teams 284
Advantages of Post-trauma Debriefing 284
Review of Literature 284
Recommendations 285
Key Points 285
References 285
37: Program Evaluation and Assessment of Learning 287
Program Evaluation 287
Outcomes-Based Program Evaluation 287
Program Evaluation Designs 288
Process-Based Program Evaluation 288
Assessment of Learning 289
Reliability 289
Validity 290
Summary 291
Key Points 291
References 291
38: Teaching Technical and Procedural Skills 293
Introduction 293
The Domains of Learning 293
The Cognitive Domain 293
The Psychomotor Domain 293
The Affective Domain 293
Principles of Psychomotor Skills Development 294
Conceptualization 294
Visualization 294
Verbalization 294
Practice 295
Feedback 295
Skills Mastery 295
Skills Autonomy 295
Relevance of the Steps of Psychomotor Skills Development 295
Feedback 295
Classification of Feedback 296
Effectiveness of the Paradigm Shift in Surgical Skills Training 296
Key Points 296
References 296
39: Multiple-Choice Review Questions 298
Chapter 1: The Genesis of Crew Resource Management: The NASA Experience 298
Chapter 2: Evidence Supporting Crisis Resource Management Training 298
Chapter 3: Leadership Theories, Skills, and Application 299
Chapter 4: Teamwork and Communication in Trauma 299
Chapter 5: Situational Awareness and Human Performance in Trauma 300
Chapter 6: Paramedics and Nonmedical Personnel 300
Chapter 7: Transport Medicine 301
Chapter 8: Trauma Team Structure and Organization 301
Chapter 9: Interprofessional Trauma Team Roles 302
Chapter 10: The Trauma Bay Environment 302
Chapter 11: Quality Improvement and Trauma Quality Indicators 303
Chapter 12: Putting It All Together: Quality Control in Trauma Team Training 304
Chapter 13: Trauma Resuscitation 304
Chapter 14: Damage Control Resuscitation 305
Chapter 15: Damage Control: From Principles to Practice 305
Chapter 16: Trauma Team Decision Making 306
Chapter 17: Emergency Critical Care Procedures 307
Chapter 18: Trauma in the Pediatric Patient 307
Chapter 19: Trauma in Pregnancy 307
Chapter 20: Medical Comorbidities and Trauma 308
Chapter 21: Basic Trauma Ultrasound 308
Chapter 22: Trauma Ultrasound: Beyond the Fast Examination 309
Chapter 23: Telemedicine and Future Innovations 310
Chapter 24: Imaging in the Stable Trauma Patient 310
Chapter 25: Disaster Medicine 311
Chapter 26: The Multicasualty Trauma 311
Chapter 27: Critical Incident Team Dynamics and Logistics 312
Chapter 28: Terrorism and Urban Trauma 312
Chapter 29: Tactical Emergency Medicine, Procedures, and Point- of-Care Evaluation in Austere Environments 313
Chapter 30: Trauma in Austere Environments: Cold Injury and Hypothermia 313
Chapter 31: War Zones and Biological Warfare 314
Chapter 32: Nuclear Injuries 314
Chapter 33: Trauma and Surgical Capabilities in Space Exploration 315
Chapter 34: Designing a Simulation Curriculum 315
Chapter 35: Designing Multidisciplinary Simulations 316
Chapter 36: Constructive Debriefing for Trauma Team Education 316
Chapter 37: Program Evaluation and Assessment of Learning 317
Chapter 38: Teaching Technical and Procedural Skills 318
Index 319