Mindset of the Resuscitationist: Organizing the Room
- Jun 13th, 2017
- Brit Long
Author: Brit Long, MD (@long_brit, EM Attending Physician at SAUSHEC) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)
Emergency Medicine is based on caring for any patient who walks in the door, any time, with any complaint. Our specialty is privileged with evaluating and managing these patients, but one of the most important settings where we make an immediate difference is in resuscitation of the critically ill patient, whether medical or surgical. Each ED varies in terms of setting, resources, and personnel available, but one thing is common: we excel in the resuscitation of the critical patient.
How do you prepare the room for a resuscitation? More importantly, how do you prepare your mind, your team, and your room for the critical patient requiring resuscitation?
The key to the Leader Mindset for resuscitation includes several components: 1) Master Yourself, 2) Control Yourself, 3) Master the Environment, 4) Master the Patient and Scenario, and 5) After the Resuscitation.
1) Master Yourself:
To master yourself, you need to train for resuscitation and use positive thinking. “Perfect practice makes perfect.” Simulation and running through scenarios and complications are key to forming muscle and mental memory. One of the best simulators present with you 24/7 is your brain. Before every resuscitation you know is coming, or if you have down time, run through the patient scenario second by second. Visualize each procedure, each order, each action you take, along with potential complications. This visualization and simulation will prepare you for the real world patient and resuscitation. Self-dialogue is valuable as well, with positive self-talk in short phrases, using first person/present tense, and repeating key phrases. Positive phrases such as “I know I can do this” and instructional phrases “focus on placing my finger into the pleural cavity for a finger thoracostomy” can go a long way into improving your care.
2) Control Yourself:
We are human, and I don’t know about you, but I have made many mistakes during resuscitation. To limit potential errors, I actively unload as many items as I can from my cognition. With any critical patient, cognitive unloading is essential to ensure you process the evaluation and management (continue your medical decision making). External devices (such as an app like WikEM, PalmEM, etc.) and checklists can help prevent misses and provide cognitive stop points. Minimizing interruptions during the resuscitation is advised, but not always possible.
Before stepping in the resuscitation bay, medical or trauma, I take several deep breaths to center my thoughts and focus on the patient in front of me and reframe my thinking. I ask myself: “What do I know, what do I expect to see/smell/hear when I enter the room, what will I change, and who are the members of my team?”
3) Control the Environment and the Team:
To be a leader, you must act, look, and sound like a leader. Most centers have a specific spot where the leader stands. If you can, lead from one end of the bed. I like to think of a trauma or sick medical resuscitation as the setting for a mob. You never know who is going to show up, and you need to control this mob. Ensure everyone, and I mean everyone, knows you are the leader. Every so often, verbalize what has been done, the goal, and the plan for everyone in the room to hear. This is also where noise and crowd control are important. You as the leader may need to designate one person to control these aspects.
The leader of a resuscitation is:
- Present in the resuscitation room prior, during, and after the resuscitation
- Assembles the team prior to arrival
- Leads the team in planning care
- Assigns and clarifies roles
- Positioned in the correct or typical leader location
- Ensures orders come from only the leader, not someone else (even a specialist)
- Receives report on the patient
- Reinforces the leader role during the resuscitation and roles of others
- Ensures communication and flow are smooth
If you work in a setting with just one physician (you), a nurse, and a technician, you will need to rapidly task switch from running the resuscitation to performing the history, exam, or procedure. You cannot multitask; this is a myth. Rather, emergency physicians are experts at rapidly task switching. If you know that you will need to complete a procedure, understand the importance of task switching. Once completed, step back into the leader mode.
Teamwork and clear dynamics are vital to every resuscitation. Just like the heart with one sinus pacemaker, a resuscitation team should have one leader. A team with multiple leaders, or a team with an unclear leader, will experience discord. The emergency physician is the leader of the resuscitation. A good leader understands each member’s role in the resuscitation and ensures they know their role and are empowered to perform it.
The team is the primary resource in managing the critical patient, though this team varies. If you work in a large center, you may have several nurses, technicians, and physicians. The team leader in this scenario acts as just that: the leader. The primary exam, secondary exam, and procedures are delegated to another physician or provider, though this isn’t always possible in centers with one physician, where he/she will lead the resuscitation, conduct the primary/secondary exams, and perform procedures.
A primary role of the leader is to ensure roles are clearly established and understood for all team members before the patient arrives. The team structure with roles should augment the resuscitation efforts. Many centers will standardize positions and roles for members. The team leader must adapt to what he/she has available for personnel, layout, and resources.
The emergency physician leading the team must empower the nurses and technicians. Each member of the resuscitation team should be competent, communicate well (assertive, but not overly aggressive), possess an in-depth knowledge of the room and system, pay attention to detail (where and what type of IV is present in the right antecubital fossa?), adapt to the situation, work hard, and anticipate the team’s and patient’s needs. The team leader should ensure respect is maintained among all team members, which can be difficult in the emotionally charged and intellectually challenging resuscitation arena.
Room Preparation and Equipment
The Leader must control the workspace. Do you have enough space, light, and equipment? The following is a list of considerations to help optimize room preparation and ensure all necessary equipment is available. This list is primarily for the trauma resuscitation, though components of this list are also essential for medical resuscitations (US, bed preparation, airway equipment, etc.).
– Personal Protective Equipment for traumas – Team safety is paramount, and many of the patients we care for have diseases that best stay with that patient. Gown, mask, eye protection, and gloves are needed for every resuscitation.
– Full sterile precautions are needed for central venous and arterial line placement. However, the crash situation may require fast access or monitoring that may require sacrificing aspects of full sterile precautions.
– Ultrasound with phased array, curvilinear, and linear probes should be turned on, working, and gel ready.
– Every bed in the resuscitation bay requires the following: C collar, suction with setup (at least two), oxygen, IV setup (at least two), cardiac monitor, BVM, Airway Equipment, Mayo stands (3), Zoll monitor with cables and battery, thermometer, IV pump, fluids, blanket, rapid infuser, bair hugger, pelvic binder, splinting material, Foley, NG/OG tubes, blood tubes, VBG.
– Blood products are rapidly available.
Trays: I like to have three equipment trays, though a fourth empty trace is nice just in case. Medical resuscitations may require airway and central line trays.
– Airway Tray: Several different airway tools are necessary. Mac 3 and 4, Miller 2 and 3, Videoscope, stylets, scalpel, ETT’s of different sizes (5.5-8.5), BVM, bougie, LMA (or other airway device such as King). The equipment for a surgical airway must always be present in case of a failed airway.
– Chest Tube Tray (at least one): One finger in the chest is the most important aspect of this procedure. Otherwise, scalpel, suture 2-0 silk, sterile towel pack, 36 F chest tube, chlorhexidine, tape, and Vaseline gauze compose the rest of this tray. A pleurovac should be ready.
– Central Line Tray: A central line kit, sterile gloves, silk suture (size 0), sterile towels, chlorhexidine.
The essential equipment should be checked at least once per shift, as well as after each major trauma. Just as an example, in terms of airway equipment, everything is ready within reach and tested before patient arrival. I like to do this before each shift.
One example of a room setup is below:
This above diagram is possible in a large center for resuscitations; however, this is not always the case. One nurse, technician, and physician may manage patients presenting to a smaller ED, including medical patients.
4) Master the Patient and the Scenario:
Overall, always consider your ABC’s and Life, Limb, and Eyesight threats first. Know the life-saving, limb-saving, and sight-saving procedures, and have that equipment ready. The decision to act is oftentimes the most difficult part of any procedure. If your gut feeling is that this patient needs intubation, or you need to activate massive transfusion protocol, or a chest tube is needed, then stop for one moment and actively consider why this is needed. Listen to that gut feeling that is a result of countless patient interactions and resuscitations. Be alert to potential issues, assess the patient for these issues, anticipate what is needed, decide, and act.
Now let’s move to the scenario, or what is required moment to moment…
Prearrival – Listen to the report if possible. For trauma resuscitations, the injury, mechanism of injury, interventions, airway, mental status/GCS, and vital signs are all important. For the sick medical patient, you need the chief complaint with symptoms, interventions, and vital signs. Make sure monitors, leads, airway equipment, medications, and ultrasound are ready. Even if the patient is intubated, have sedative/paralytics ready with equipment.
- What information do we have on the patient(s)?
- Who is doing what? (Or, role assignment)
- What are we expecting?
- What are other possibilities?
- What is the plan of action?
- What contingencies are necessary?
Anticipated actions and procedures – This is where the prearrival briefing and discussion among team members can have a massive impact. If the team leader or procedure physician has discussed potential procedures and scenarios, the equipment needed for these procedures should be rapidly available. Don’t just discuss it or visualize it; have the tools to succeed. If you know a patient will have a radius fracture, splinting material should be applied after the primary and secondary surveys for patient comfort.
Following this, run through if-then scenarios, such as “If the patient is hypotensive and requires intubation, then immediate resuscitation with fluids and vasopressors should be initiated before intubation,” or “If the patient with the knife wound to the anterior chest loses pulses, then we will perform immediate thoracotomy.”
Arrival – The person at the head of the bed coordinates the patient move, not the EMS team. The team leader should ensure the primary survey is performed immediately, and the leader should ask the EMS team to stand by for report (this varies on center). As soon as the patient is transferred, reaffirm the primary survey and ensure monitors are working and access is obtained. A manual blood pressure should be obtained first, as the resuscitation hinges on this value. Nurses and medics have two attempts at IV. After that, IO access is needed.
The Report – Similar to the prearrival report, the team needs information concerning injury, mechanism of injury, vital signs, mental status, and interventions. Changes in patient status from pickup to delivery provide important information.
For more on mastering the patient and scenario, see http://www.emdocs.net/the-crashing-trauma-patient/ and http://www.emdocs.net/unstable-patient-gi-bleed/.
Communication can assist in avoiding errors. If the team leader provides a verbal order, the nurse, technician, or other physician should be able to verify the order verbally with the team leader if the potential action can result in patient harm. The team leader should consider the order and offer an explanation. Cross monitoring by other team members is also advised. Each stage of the resuscitation should be verbalized by the leader. For example, “We have completed our primary survey, and we are now moving to our secondary survey,” or “The lactate has returned at 4.2 mmol/L. Mark, can you please bolus 1 L of lactated ringers immediately and start levofloxacin and zosyn?”
The importance of stop points
Every several minutes, such as after the primary survey, after a key procedure, following a study result (such as a lactate of 4), and after the secondary exam, reevaluate the situation deliberately. Consider the patient, what the team has completed, and what next steps are. These are designed to prevent bias. During these stop points, verbalize the situation, what has occurred, what you have found on your studies, and the plan moving forward. This is vital during the resuscitation, as well as ensuring the appropriate diagnosis and management occur. You may need to take complex or difficult resuscitations step by step.
5) After the Resuscitation:
Discussion with Family
If family members or loved ones are present, the team leader or nurse leader should address them and discuss what the family member knows, what has occurred with the patient, and what the plan is for the patient. The team leader must be honest and upfront with the family. If the patient is dying or has died, the team leader should let the family know. Please see this post for more: http://www.emdocs.net/empathy-emergency-department/
Team discussion of the case or debriefing are important for learning and handling stress. Each member of the team can provide valuable insight into what aspects went well and which components could be improved. This component can cement key lessons for all involved.
After this debrief, think through your own actions, what went well, and what could have gone better. Then, reset your own mind and yourself. After all, you probably have a full waiting room and more critical patients.
Please see these great resources on the Mind of the Resuscitationist from EMCrit for more: