Category Archives: General

Teaching the Trauma Team

Teaching hospitals have extra responsibilities when constructing their trauma activation team. They are typically charged with educating trainees from a variety of disciplines, including residents, medical students, and students from other disciplines (EMT, PA, NP). The activation process must not only provide rapid and high quality trauma care, it must also teach these students how to provide that care.

Residents can be integrated into the typical physician roles on the team: airway and primary examiner. To integrate more trainees, these roles can be split further. For example, the examiner’s role can be split into a primary examiner and a secondary examiner with separate, lesser responsibilities. PAs and NPs can be integrated into these roles as well.

One of the most important “additions” to the team that allows education of senior level residents is the Team Leader. This role allows the trainee to learn how to direct the overall resuscitation and allows them to practice making management decisions on the fly. Typically, the Team Leader does not actually touch the patient, allowing the other examining physicians to do this and learn their specific roles. Each role can be assigned to an appropriate level resident, so that they move to higher levels as they progress through their training program.

Here is a template for a trauma team that allows four trainees (yellow balloons) to participate. One faculty members supervises all of them.

At our Trauma Center, we have these four trainees plus another Emergency Medicine resident who performs the FAST exam, if indicated. Two faculty members participate, one trauma surgeon and one Emergency Medicine faculty. Our total team size is 12, so it must be well-coordinated in order to avoid chaos.

Medical and paramedic students are usually confined to the periphery to take notes (H&P) or just observe.

Please leave your comments describing the composition of your team and what makes it run well.

Tomorrow: qualifications of your trauma team personnel

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Who’s On Your Trauma Activation Team?

Yesterday’s video highlighted members of the trauma team at a medium size teaching hospital. Today, I will discuss who actually needs to be on the team.

The decisions leading to the composition of your trauma activation team are complex ones. The key is to look at your needs during a typical trauma resuscitation, and look at the resources available within the ED and the hospital as a whole.

The trauma resuscitation team can consist of as few as 4 to as many as 15 or more people! The first item to consider is who is available to go to a trauma activation? If your ED staff is small, the team will be small, or you will have to draw personnel from other areas of the hospital.

The absolute minimum personnel are:

  • 1 Physician
  • 1 Nurse
  • 1 Scribe
  • 1 Assistant (can be physician, nurse, or other)

Using the minimum contingent will force the use of ATLS the way it is classically taught, with the physician sequentially going through the entire process. Additional physicians and nurses allow overlapping portions of the evaluation and treatment and will also speed up the resuscitation process.

An ideal team for a non-teaching hospital is:

  • 2 Physicians
  • 2 Nurses
  • 1 Scribe
  • 2 Assistants

This allows for the physicians and nurses to split their responsibilities (airway, exam, IV access, monitoring) and assures adequate help with patient safety, evaluation and restraint.

Additional personnel can be added from outside the ED to provide a better interface with other hospital services. Examples include:

  • OR representative – communicates with the OR charge nurse to enable rapid access to an OR if needed
  • Lab representative – interfaces with blood bank to provide access to blood products
  • ED nurse – acts as an interface between the resuscitation room and services in the rest of the ED (supplies, calls to consultants, etc.)
  • Anesthesiologist or CRNA – to provide support of the difficult airway
  • ICU nurse – can provide additional nursing support or take other roles
  • Ultrasound tech – may perform FAST if the resuscitation physicians do not have this skill
  • Pediatric intensivist / pediatrician – assists with management of small children

Tomorrow: trauma teams in the teaching hospital

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Evaluation After Head Injury in Adolescents

Traumatic brain injury (TBI) is the most common cause of death in children. Even mild concussions can cause some degree of functional impairment. Many clinicians believe that the degree of impairment correlates with the initial Glasgow Coma Scale score (GCS), although this has only been shown in adults. This has led many hospitals to perform cognitive screening selectively, usually on adolescents with lower GCS scores.

A recent study by Goold and Vane at the Cardinal Glennon Children’s Medical Center in St. Louis, and the University of Vermont College of Medicine in Burlington looked at the correlation between GCS and level of impairment, and ways to determine which groups of adolescents need more sophisticated cognitive testing to evaluate deficits.

A total of 609 young adults age 13-21 with brain injuries were identified, and a cognitive screening test was performed (Occupational Therapy Head Injury Mini Screen [OT HIMS]). There was no correlation between GCS and the components of the OT HIMS. Interestingly, the GCS did not predict which patients were discharged to rehab centers either.

The Bottom Line: Adolescents can develop significant cognitive deficits or behavior issues after any degree of head injury. Because of this, it is not possible to selectively screen for cognitive deficits. All adolescents age 13-21 should undergo screening with an instrument like the OT HIMS after head injury.

At our Level I Pediatric Trauma Center, we consider a child to have a TBI if:

  • the mechanism involves head impact and
  • any of the following apply:
    • known or suspected loss of consciousness
    • cannot remember the event
    • parents detect any change in behavior

All of these children undergo a TBI screen performed by Gillette Children’s Specialty Hospital physiatry, occupational and physical therapy services. If needed, they receive followup in the Gillette Minor Neurotrauma Clinic.

Reference: Goold D, Vane DW. Evaluation of Functionality After Head Injury in Adolescents. Journal of Trauma 2009;67:71-74.

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