Frontline Medicine and EMCrit’s Logistics over strategy

2 Jan

Most of you will have seen this BBC show linked to by Life in the Fast Lane a few weeks ago. If so I can heartily recommend you watch it now.

[youtube http://www.youtube.com/watch?v=_8rKzUk1wPg&w=560&h=315]

There’s a lot of talk about how modern warfare has pushed forward the boundaries of medical care, and how trauma care in Iraq and Afghansitan is seeing people survive who would likely never survive in a civilian setting.

To me it seemed that the emphasis was on science and technology being the key factor in saving the lives. The now popular 1:1:1 transfusion stuff got a prominent role.

However I think they missed a great opportunity to point out what I suspect is the really key feature of survival – the team work/logistics of it all.

I don’t mean to dismiss 1:1:1 transfusion; while I don’t think it’s “proved” in any way yet, it has usefully put a focus on thinking about what we’re doing in resuscitation and I imagine it will turn out to be pretty close to the truth eventually.

What I find much more interesting (and eminently more translatable to civilian settings) is the team work and logistics on display in military settings.

One of the very best things Scott Weingart has promoted (and there are many to choose from!) was the idea of logistics over¬†strategy¬†in resuscitation. Be sure you’ve listened to the episode before your next resuscitation.

Here comes my OBM (opinion-based-medicine):

  • the most important part in saving lives in such a resuscitation are the logistics and how the team makes decisions.

I have observed and partaken in many chaotic and dysfuncitonal resuscitations. And I’ve taken part in some wonderful ones. Part of this is leadership – a clear leadership, where those involved listen and trust the decisions of the person at the foot/side/head of the bed.

For a team to work the way it does in Camp Bastion (or somewhere like Shock Trauma in Baltimore) takes a lot of practice. And not just on every trauma that comes in but in simulated settings, with feedback and video recordings and timings and all that.

It takes time set aside to think through what the team will do in different situations, and which items take priority in a resus. This is way beyond the rather silly moulages we do in ATLS. It involves putting together all the isolated individual skills that we learn in books, on courses or on all the excellent blogs and podcasts, and putting together all these skills with other docs and nurses and staff and making sure we can pull it off smoothly.

For example, I know how to do a FAST exam. Technically I know how to do one, and I have performed a number of them to try and put into practice, but if we want to do it properly (and remember in the UK/Ireland, we don’t seem to be that great at this yet) then we need to practice getting a FAST done while all the ABCs are happening at the same time, not just in the dry, sterile algorithmic fashion that we all learned.

In my (fairly) limited training so far, I’ve not seen much of this. The idea sounds great but in practice, we’re all busy and never really manage to get enough people in the same place at the same time to manage to get it done. In fact the only time we do manage to get all the same people in the same place at the same time is when we have a major trauma rolling in the door in 5 minutes…

And I’m not quite sure that’s good enough.

(Incidentally I see Amit Mani has something relevant to this on his Blog too)

6 Replies to “Frontline Medicine and EMCrit’s Logistics over strategy

  1. Andy, logistics are so important!
    Any chance I get, I like to pimp the residents – they all know what to do, but when I ask them things like “what’s in the emergency airway trolley”, or “how do you make up that infusion”, “how do you zero the art-line”, mostly they just stare at me blankly. I work with such great nurses in my hospital that you rarely need to know those things, but sometimes, when you’re in an unfamiliar setting, perhaps in the country, – YOU may be the one that will have to draw up the drugs, YOU may be the one that has to know how to set up ETCO2 monitoring etc..

    The use of simulation is going to absolutely sky rocket, for both the teaching of technical, and non technical skills. It’s an exciting time to be in emergency medicine, because we are really pushing the boundaries, as we start moving away from traditional cook book medicine (ATLS, ACLS), and start individualising care to our specific patients.

    Hope you’re enjoying being back in ED Andy.

  2. Andy, Excellent points on a topic I care about deeply. I think another factor, perhaps the prime factor is competence of the team to perform the tasks they need to without the leader’s intervention. At STC, there was an attending trauma anesthesiologist at every airway, meaning all the leader had to decide was is an airway needed, not how to make it happen. Techs placed the IVs and drew the blood without any help needed. Nurses were absolutely competent at all of their tasks. As a result, no teaching was needed during the actual resus.

    So how do we develop this; residents or team members must know their skills and procedures down cold, before trying to develop team interaction skills.

    • Hi Scott. Cheers for the comments. That podcast really hit home for me so thanks.

      Personally I know I’m nowhere near slick and practises enough to pull off a lot of the resus tasks. And because most places don’t see that much big trauma it’s hard to get the skills and rehearsal needed to pull it off.

      And you’re right the skills must come first. There’s no point tryin to deal with the egos in a resus if they can’t do the job anyhow!

  3. I totally agree with most of whats written. I’ve had the opportunity to work along side some of the best in the business, like Tim Hodgetts – he is usually thinking 3 steps ahead, extending the envelope – even in civilian practice.
    A lot of this takes practice, and outside centres that see big trauma often, it can be hard to develop these skills / teamwork.

    • Hi David

      Thanks for the comments.

      I suppose for places that don’t see that much trauma, that’s where the usefulness of simulation (either official or improvised) comes in. I know it’s not quite the same as the real thing, but it seems vital.

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