Tag Archives: human factors

Leadership & experience count in trauma resuscitation

These findings shouldn’t be a surprise – and the authors acknowledge a number of methodological weaknesses in what is essentially a pilot study – but the conclusions are worth reminding people about.

INTRODUCTION: Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members’ perception of leadership and the efficiency of the injured patient’s initial evaluation.

METHODS: We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL’s ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p < 0.05, statistically significant).

RESULTS: Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27-72). Leadership scores were divided into 3 groups post facto: low (18-45), medium (46-67), and high (68-72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p < 0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p < 0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p < 0.05).

CONCLUSION: The trauma team’s perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

Trauma leadership: does perception drive reality?
J Surg Educ. 2012 Mar-Apr;69(2):236-40

It’s up to you….

Sometimes you have nothing to lose by doing a procedure that you may never have done before, if the patient is going to die or deteriorate without it.

In today’s competency-based-training-and-accreditation climate (a good thing), how does one achieve competence in a procedure that may be too rare to have even been seen, let alone practiced under supervision and formally assessed?

I spend a lot of time and energy trying to convince colleagues and trainees that there are situations where the benefit-harm equation is in favour of acting, despite reservations they may have about inadequate experience or training. These situations often require ‘surgical’ procedures. What they have in common is that they are all relatively simple to perform, but may save a life, a limb, or sight which otherwise may almost certainly be lost.

How best to train for these procedures, some of which may be too rare even for ‘see one, do one, teach one’ in an entire residency program? Simulators? Animal labs? Cadavers?

Slide from 'Making Things Happen' Course

In my view, the answer is to use the most high fidelity simulator in the universe – the human brain. It is those professionals who mentally rehearse the scenario and visualise the procedure over and over who are most likely to act when the patient needs it most. Several colleagues of mine over the years can recount incidents in which the indications for a thoracotomy or hysterotomy were present but they failed to act, talking themselves out of doing the procedure with a range of excuses from ‘I hadn’t had enough training’ to ‘No-one in the room wanted to do it’. Don’t be one of those! Get simulating now – you have all the equipment you need!

Ten steps to making it happen – be prepared

1. Pick a procedure (eg. thoracotomy)
2. Be ABSOLUTELY CLEAR on the indications – this helps remove any doubt when the time comes
3. Learn how to do it (talk to colleagues, read a book)
4. Know where the required equipment is kept
5. Start practicing in your mind – visualise seeing the patient, what you will say to your staff, where you will locate your equipment, what you will do procedurally step-by-step
6. Visualise possible outcomes and what your next steps would be (tamponade plus cardiac wound in a beating heart, tamponade plus wound plus VF, return of spontaneous circulation with bleeding from internal mammary arteries)
7. Read more and talk to more colleagues based on questions arising from your ‘simulations’
8. Travel, go on a course, get access to animal or cadaver labs if that’s an option in your setting
9. Speak to people who have done it in YOUR context (eg. for a resus room thoracotomy, talk to emergency physicians who have done it there, rather than a cardiothoracic surgeon who has only ever done them in the operating room)
10. Find an excuse on shift to talk about it to colleagues and rehearse the steps, locate the equipment, and so on. Remember: REPETITION IS THE MOTHER OF SKILL!

What’s on your list of life/limb/sight-saving procedures that can’t wait for someone else to do? Did I miss any? Should skull trephination be there? Comments welcome!

Paramedics control space

Paramedics practice ‘‘in the street’’ and perform in ‘‘a context rife with chaotic, dangerous, and often uncontrollable elements with which hospital-based practitioners need not contend’ We knew that, but what isn’t known is how more experienced or expert paramedics differ from novices in scene management. This qualitative study involving interviews of 24 paramedics describes the ‘space control theory’ – how paramedics establish control over their immediate workspace to effectively deliver patient care. It’s not big on detail, but at least this paper documents for hospital-based ambulance medical advisors that there is more to paramedicine than purely clinical factors, which is why insistence on hospital-derived clinical treatment algorithms might sometimes be inappropriate in the field. I’ve emailed the author for more details.

Introduction to the ‘‘space-control theory of paramedic scene management’’
Emerg Med J. 2009 Mar;26(3):213-6