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162
E. Walser et al.
necessity of training to optimize performance—in order to
best care for the injured trauma patient [1].
Ideally, the Trauma Team should be present before arrival
of the trauma patient, but this requires both advance warning
of arrival and available personnel. In the absence of a Trauma
Team, the Emergency Department (ED) response to an
injured patient typically begins with an assessment by an
Emergency Medicine (EM) physician, who may have several
other patients to follow and can accomplish tasks in succession only. In this setting, ATLS dictates the sequence of care
and should be followed until the patient stabilizes.
Consultation of additional surgical specialties might only
occur if deemed necessary after the assessment, thereby
delaying any response. Trauma patients frequently present in
physiologic extremis and require urgent diagnostic and therapeutic interventions immediately upon arrival. The implementation of dedicated Trauma Teams has been shown to
improve patient outcomes [11, 12, 25] and is the standard of
care in North American trauma centers [5, 13].
Table 21.1 Composition of trauma team in a high-income country [43]
Role Responsibility Position Personnel
Activation
Team Leader Coordinate team activities, review
all data, formulate denitive
plans. In lower resource setting,
may also perform primary survey
Airway Establish a clear airway, intubate
as required
Respiratory Therapist Assist in intubation and ventilator
setup
First Assistant Primary and Secondary Survey,
assist in procedures if not
additional physicians
Second Assistant Procedures (chest tubes, lines,
FAST. Assist with log roll
Primary Nurse First set of vitals, intravenous
access, drawing of bloodwork
Secondary Nurse Medication draw-up and
administration, assisting primary
Recorder Documentation of resuscitation Computer Nurse
X-Ray Technician Performs X-rays as dictated by
team leader
Additional members
Service Responsibility
Orthopedic Surgery Consult as needed for the management of traumatic fractures
Neurosurgery Consult as needed for the management of traumatic brain injury
Social Worker Coordinate family care and support
Chaplain Coordinate family care and support
Trauma Floor Nursing Provide care on the trauma oor (lab draws, vitals, medication
Intensive Care Unit Nursing Provide care in the intensive care unit (lab draws, vitals, medication
Trauma Registrars Data-drive feedback to the Trauma Team
Blood Bank/Lab Technicians Participate in development and implementation of transfusion
Adapted from Hoff etal. and the WHO “Guidelines for essential trauma”
EM Emergency Medicine, FAST Focused Assessment with Sonography for Trauma
A Trauma Team Activation (TTA) is the logistical
sequence of notication of members of the team, as well as
other key members of an institution that may not attend the
trauma but are frequently involved in the care of the severely
injured patient. Criteria for a TTA should be tailored to a
particular institution’s resources and setting, and selection of
these criteria dictates which patients will be cared for by the
Trauma Team as opposed to EM physicians [5]. As even
delayed TTA has been associated with prolonged hospital
stay [26], the balance between over- and under-triage must
be continuously monitored [5, 27]. How a medical facility
meets the needs of the trauma patients will vary among countries; however, the ATLS [1] and WHO guidelines [28] form
the backbone of the standards of care for any trauma facility
(Table21.1).
The goal of early Trauma Team Activation (TTA) is to
mobilize the team members and hospital resources before
the patient arrives, so that life- and limb-saving interventions
can be provided immediately upon arrival. As well, it is also
Foot of the bed EM Physician or Surgeon
Head of the bed EM Physician or Anesthesia or
Surgeon
Head of the bed Respiratory Therapist
Patient right EM Physician or Surgeon
Patient left EM Physician or Surgeon
Patient left Nurse
Patient left or right Nurse
Away from patient until needed Technician
administration)
administration)
protocols
21 Trauma Team Structure andOrganization
163
important to share pre-hospital information with the team in
preparation for the patient arrival, and allow members of the
multidisciplinary team to garner personal protective equipment, including lead shielding.
The size and composition of the Trauma Team may vary
with hospital size and resources; additionally, institutions
may dene different levels of activation based on the severity
of injury. Most high-level TTAs within a resource-rich environment include core team members from anesthesia, emergency medicine, general surgery, neurosurgery, orthopedic
surgery, respiratory therapy, and nursing. The personnel
attending TTA varies by level of activation, institution, country, and accreditation [5]. Airway obstruction is a rare but
exceedingly rapid cause of trauma-related death. Severe
brain injury and torso exsanguination cause the vast majority
of all trauma-related deaths [25]. Extremity injuries are
among the leading causes of disability after injury [29, 30].
Other individuals not directly involved in resuscitation are
activated such as social work and security. Given the frequent need for rapid access to resources, notication of radiology (technicians and physicians), blood bank, operating
room, and critical care leadership is prudent. Smaller hospitals may only be able to mobilize smaller team, and lessseverely injured patients may only lower-tier activations.
All team members, including surgical specialists, perform
their investigations and interventions in accordance with
established principles and guidelines. The TTL’s purpose is
to coordinate the activities of all Trauma Team members and
to ensure that each phase of care is performed thoroughly
and rapidly, from the resuscitative phase, to the imaging or
operative/intervention phase, and nally to the transfer of
care to the ward, operating room, or intensive care unit. This
role requires medical knowledge, technical skill, and ability
to lead a team in a high-stress environment.
Team Members andRoles
As discussed previously, the composition of the Trauma
Team is variable. Table21.1 lists typical members of the
Trauma Team. Depending on the level of TTA, members
may be added or subtracted according to institutional guidelines and accreditation of centers. There really is no right or
wrong formula; the Trauma Team composition should be
based on specialties and personnel available as well as
resources.
Trauma Team Leader (TTL)
The Trauma Team Leader is an experienced physician or
surgeon that is the “captain” of the Trauma Team [5]. The
leader provides expert management of the trauma patient
during the resuscitative phase of their care. This includes
preparing the team prior to the patient’s arrival (pre-hospital background such as number of individuals involved,
mechanism of trauma, severity of trauma, and/or injuries),
managing the patient in the trauma bay, caring for the
patient during transport and during diagnostic imaging, and
providing care until a satisfactory handover has occurred to
appropriately skilled personnel, who will continue managing ongoing care requirements. The TTL must have the
experience and medical expertise to guide the trauma
patient through these phases of care, as well as exhibit the
ability to work within a team framework and be able to
assume its leadership. [31]
The training background of the TTL varies by center, but
the TTL is often a surgeon, emergency physician, or another
acute care physician with an interest/additional training in
trauma. Several studies have compared the outcomes of
patients treated by surgeon- and non-surgeon TTLs. There
were no differences in survival or length of stay, but one
study identied a higher rate of missed injury in patients
treated by non-surgeon TTLs [32, 33]. In the United States,
trauma surgeons serve as the predominant TTLs at Level I/II
centers, although the use of emergency medicine TTLs in
this setting is still supported [34]. This likely reects the
much higher rate of penetrating injuries in the United States,
which are more likely to require immediate surgical intervention. [35] In settings where the TTL is not a surgeon,
there must be a robust protocol in place to rapidly activate a
surgical team.
The TTL must have exceptional skills as a communicator,
manager, and collaborator to effectively lead the Trauma
Team. The TTL is generally positioned at the foot of the
patient’s bed and away from direct patient contact, with a
direct view of the vital signs monitor. This allows the individual to maintain situational awareness and direct all the
activity of the other team members. As highlighted in Chap.
8, this global focus minimizes the likelihood of committing a
xation error (persistent failure to revise a diagnosis or plan
in the face of readily available evidence that suggests that a
revision is necessary) [36]. The TTL is responsible for generating a shared mental model for Trauma Team members, as
well as directing communication with the operating room,
radiology department members, and critical care unit staff.
The individual will decide which diagnostic and therapeutic
interventions need to be performed and in what order. The
TTL is also responsible for ensuring that the major ndings,
summary of injuries, and treatment plan are documented in
the medical record. In the event that a patient is accompanied
by Police or presents with a stab or gunshot wound, the TTL
is responsible for interacting with any ofcer and ensuring
compliance with any jurisdictional requirements to notify
Police in the setting of such wounds, as well as protecting the
safety of Trauma Team members [37, 38].
164
E. Walser et al.
Airway
Assessment of the airway is the rst step of ATLS in singleprovider environments, and in well-resourced settings, a
single provider should focus on this critical system. While
this role is generally lled by an Emergency Medicine
Physician or Anesthetist, any provider highly skilled in airway management can take on the role; often Trauma Surgeon
or Critical Care attending or senior residents. This person
should be positioned at the head of the bed and will be delegated with managing most “Airway” issues often with the
help of a respiratory therapist. Part of this position includes
communicating airway concerns with the TTL and identifying the need for securing an airway. One exception to the
responsibilities for the Airway provider may be in the “difcult airway” that requires cricothyrotomy. In many trauma
centers, a trauma or general surgery senior team member is
responsible for performing surgical airways. In conjunction
with other members of the team, the Airway provider may
also be asked to help with managing “circulatory issues.”
Particularly, they may be asked to place central venous catheters, transfuse blood products (along with nursing team
members), and place arterial lines. Also, as part of the
adjuncts to the primary survey of ATLS, the Airway provider
may be asked to place orogastric or nasogastric tubes. In the
event that the airway provider is not from Anesthesia, this
service should be involved immediately for patients requiring operative intervention.
Respiratory Therapy
The Respiratory Therapist works with the Airway provider
to assist in assessment and management of the airway. They
are specically responsible for setting up equipment including airway devices and adjuncts, ventilators, arterial lines,
end-tidal CO2 monitoring, and drawing and running arterial
blood gases. This role will be discussed further in Chap. 22.
Emergency Medicine Physician
The role of the Emergency Medicine varies greatly depending on the hospital and even country, but in almost all
instances the Emergency Medicine physician will be the rst
responder to trauma activations without advance warning,
and in some circumstances remains the lynchpin of the
Trauma Team in the TTL role. This is often the case in nontrauma center hospitals. Once other members of the team
arrive, their broad skillset allows them to effectively substitute for many other team members. Airway management,
uid resuscitation, performing FAST (Focused Assessment
with Sonography for Trauma), and even some emergency
surgical procedures such as cricothyroidotomy and thoracotomy fall within the scope of a skilled emergency medicine physician. The role they ll as part of the Trauma Team
is therefore variable and often dependent on local medical
culture. Some countries involve Critical Care physicians to
fulll this role.
General Surgery
The General Surgery representation on the Trauma Team
typically consists of a junior and/or senior resident. In some
countries General Surgery presence has been completely
replaced by Trauma Surgery. They should be positioned at
the patient’s sides. Using the ATLS paradigm, the general
surgery team members function as rst assistant and are usually asked to perform the primary survey of trauma patients.
A second member of the general surgery team (often replaced
by an Emergency Medicine Physician or resident) is usually
responsible for placing chest tubes to relieve hemo/pneumothoraces. For “Circulation,” the general surgery team usually
participates in the resuscitation of patients in hemorrhagic
shock, along with the Airway provider and nursing. As part
of the resuscitative efforts, the general surgery team is often
responsible for placing central venous catheters (subclavian/
femoral). More importantly, the TTL usually delegates the
responsibility of localizing and denitively stopping major
sources of hemorrhage to the general surgery team; performing the FAST exam is an important part of the general surgery exam for major sources of hemorrhage. When FAST is
unavailable or non-diagnostic, Diagnostic Peritoneal Lavage
or Aspiration may be performed by general surgery in the
unstable patient. Major sources of hemorrhage include the
thorax, abdomen, retroperitoneum (including pelvis),
extremity, and external sites of bleeding. General surgery,
therefore—in collaboration with the TTL—determines
whether the patient requires a trip to the operating room for
laparotomy, thoracotomy, or neck exploration, to angiography for embolization, should remain in the trauma bay for
additional interventions, or can proceed with cross-sectional
imaging. In addition, general surgery is responsible for
reviewing any CT imaging of the torso, abdomen, and soft
tissues of the limbs (including blood vessels) and neck with
radiology.
Orthopedic Surgery
The Orthopedic Surgery representation on the Trauma Team
may consist of a junior resident, but often a senior resident
may be required especially for the placement of advanced
skeletal traction. They are often not part of the initial resuscitation but are consulted for the management of traumatic
21 Trauma Team Structure andOrganization
165
fractures. If part of the initial resuscitation, they should be
positioned at the patient’s pelvis and will be delegated specic roles in the assessment and management of “Circulatory”
issues in addition to maintaining primary responsibility for
“Disability” issues in the injured patient. Regarding
“Circulation,” orthopedics usually will be asked to identify
and bind unstable pelvic fractures, and identify and splint
grossly angulated extremity fractures. For “Disability and
Exposure,” the orthopedic team will specically examine all
extremities, the pelvis and spine. The orthopedic team will
be responsible for performing a detailed secondary survey of
the musculoskeletal system and will review all extremity
imaging and spine imaging. In the event of an injury to the
spine, either orthopedics or neurosurgery is generally responsible for managing this injury based on local agreements.
While not all trauma systems include orthopedics in the core
Trauma Team, it is essential that they are readily available to
participate if required based on identied or suspected
injuries.
Neurosurgery
The Neurosurgery representation on the Trauma Team typically consists of a resident and, similar to orthopedics, is
often absent from the initial trauma resuscitation until a relevant injury is identied. If part of the resuscitation, the individual is responsible for the “Disability” component of
ATLS, including assessment of the spine on log roll when
appropriate. They may make recommendations to the TTL
regarding the management of any increased intracranial
pressure. They are responsible for immediate interpretation
of the CT/CT Angiogram and discussion with their attending
surgeon regarding any operative management or ventricular
drainage. Traumatic brain injury is a major cause of death in
multiply injured patients, and early neurosurgical evaluation
is essential [25]. Similar to Orthopedics, if Neurosurgery is
not a part of the core team, they must be able to respond
quickly if required.
Primary andSecondary Nurses
Trauma nurses are generally drawn from the Emergency
Department nursing staff, and a high-tempo trauma will
often require two or more skilled nurses as an absolutely
essential component of the team. Their roles are exceptionally broad but generally include placing appropriate patient
monitoring, obtaining the rst set of vitals, inserting peripheral intravenous catheters, obtaining blood samples for the
laboratory, assistance in patient manipulation including logrolling, and acting as non-sterile assistant to a member of the
team who is performing an invasive procedure such as chest
tube or central line insertion. They are generally responsible
for administrating any medications or vaccinations. Nursing
roles will be further outlined in Chap. 22. Their importance
to the functioning of the team is difcult to understate.
Recording Nurse
The role of the recording/documenting nurse is just that: to
document, on an appropriate trauma medical record, the
important ndings of the Trauma Team in their assessment
of the patient. This includes recording vital signs, assessments, and nature and type of procedures performed. This
nurse is typically situated near the foot of the bed, in proximity to the TTL, so as to gain a view of the monitors and be
able to hear the Trauma Team’s assessment as it is relayed to
the TTL.Often acting as a nursing team lead, they are often
the most senior nurse on the team and work in conjunction
with the TTL to facilitate team communication and task delegation, especially with services/resources not directly present in the trauma bay. As mentioned previously, nursing roles
will be further discussed in Chap. 22. The electronic medical
record has greatly changed the role of the recording nurse,
and this individual is paramount to quality improvement initiatives for the injured patient. Accurate data is paramount in
root-cause analysis.
Trauma Team Activation
The Trauma Team is called into action with a Trauma Team
Activation (TTA). The TTA may be in response to prehospital information or information obtained when the
patient rst arrives to the ED.The value of having a Trauma
Team ready and awaiting the arrival of a severely injured
patient cannot be understated, as it allows for appropriate
preparation of the room and equipment, introduction and
organization of the Team, and preparation based on the anticipated injuries of the patient from any pre-hospital
information.
A TTA may occur in a tiered fashion, or have graded “levels” of response [39, 40]. Tiers should be organized based on
the requirement for immediate or subsequent intervention
and the resources required in your care. Triage should be
based on injury mechanism and clinical status, either from
pre-hospital reports or once the patient arrives in the trauma
bay. Triage systems will vary based on systems, but general
criteria for the highest-level response include but are not limited to traumatic arrest, hypotension (systolic blood pressure
< 90 mmHg), GCS < 9, penetrating neck, abdomen or torso
trauma, transfusion of blood to maintain vitals, intubated
patients, or physician discretion. For these patients, in addition to the standard Trauma Team, the Trauma Surgeon,
166
Table 21.2 American college of surgeons committee on trauma minimally acceptable criteria for highest level of Trauma Team activation [5]
1. Conrmed blood pressure <90mm Hg at any time in adults and age-specic hypotension in children
2. Gunshot wounds to the neck, chest, or abdomen
3. GCS<8 with mechanism attributed to trauma
4. Transfer patients from other hospitals receiving blood to maintain vital signs
5. A) Intubated patients transferred from the scene
OR
B) Patients with respiratory compromise or obstruction (includes intubated patients who are transferred from another facility, with ongoing
respiratory compromise but does not include patients intubated at another facility and are now stable from a respiratory standpoint)
6. Emergency Physician’s discretion
E. Walser et al.
Operating Theatre, Blood Bank, and Intensive Care Unit
may also be notied. For other patients that have evidence of
multisystem trauma but are hemodynamically normal, a
lesser activation comprising the TTL and the core Trauma
Team members may occur at the discretion of the TTL,
charge nurse, or emergency physician.
Each institution will have its own method for TTA, which
may include dedicated pagers, overhead pages, or even
“walkie-talkies” for immediate notication. Notication
may either alert the Trauma Team member to proceed immediately to the Trauma Bay or provide an update on an anticipated trauma with an estimated time of arrival. The
developing eld of pre-hospital telemedicine and teleradiology may, in the future, facilitate the transmission of important diagnostic information to the awaiting hospital Trauma
Team so that they may better prepare for the patient’s specic injuries [41].
The criteria for a graded activation must be clearly dened
by the trauma center and continuously evaluated by the performance improvement and patient safety program [5].
Inevitably, over-triage (triage decision that classies a patient
as requiring TTA when, in fact, they do not) and under-triage
(triage decision that classies a patient as not requiring TTA
when, in fact, they do) will occur, but a trauma system should
establish and monitor acceptable rates for these. Obviously,
under-triage carries a greater threat to patient care than overtriage. Suggested rates for TTA are >95% of patients with an
ISS>=16, and in <30% of patients with an ISS=<9. The
ACS/COT suggested TTA criteria are listed in Table21.2 [5].
Newer methods of determining TTA include the need for
emergent invention within 6h [27].
The Trauma Bay
The Trauma Bay, or resuscitation area of the Emergency
Department, is where major trauma patients should be
received and is the primary location where trauma patients
are initially treated. The ideal Trauma Bay has the following
characteristics: easily accessible to EMS personnel, well lit
(with OR-quality overhead lights), spacious enough to
accommodate the Trauma Team and necessary equipment,
have the ability to perform plain lm radiography, be close
to a CT Scanner, and be in reasonable proximity with direct
access to the Operating Rooms and Intensive Care Unit.
Many trauma centers have a dedicated area in, or adjacent
to, their emergency department with the ability to care for
two or more severely injured patients simultaneously. A
typical arrangement of a Trauma Bay is depicted in Fig.21.1,
with a picture of a typical Trauma Bay in Fig.21.2. It is
important that all potentially required equipment be located
within the Trauma Bay to avoid unnecessary delays.
Equipment should also be grouped together by the requirements for performing each procedure. For example, a “chest
tube package” may include a sterile cut-down tray containing appropriate instruments, with a suture, scalpel, chest
tube, sterile gown, and gloves taped on top of it, already
sitting on its own moveable table with a chest tube drain and
antiseptic solution on the lower shelf. Similar packages
should exist for central venous catheters, thoracotomy sets,
surgical airways, and arterial catheters. The contents and
accessibility of these packages must be reviewed on a regular basis by physicians participating in the care of trauma
patients. These packages should also be ergonomically
placed in the Trauma Bay, i.e., the chest tube packages
should be placed on either side of the patient’s stretcher. A
complement of airway management devices must be immediately accessible at the head of the bed; many centers have
a standardized “difcult airway cart” placed within the
trauma bay. An adequate supply of individual lead-lined
protective garments must also be available to facilitate care
while plain radiographs are obtained. Ideally, these garments are donned underneath personal protective equipment
(gown, gloves, full-face mask) by all members of the Trauma
Team as they arrive into the trauma bay, so that trauma
patient care is not interrupted when X-rays are performed.
An in-depth discussion of the trauma bay environment and
its design can be found in Chapters 23 and 24.
21 Trauma Team Structure andOrganization
167
Fig. 21.1 Trauma Team
positioning in the trauma bay.
TTL Trauma Team Leader,
EM/GSx Emergency Medicine
or General Surgery Provider,
MSK Musculoskeletal
Provider, AP Airway Provider,
RT Respiratory Therapist, N1
and N2 Circulating Nurses,
N3 Recording Nurse, DIT
Diagnostic Imaging
Technician, EDT Emergency
Thoractomy Tray, POCUS
Point of Care Ultrasound Unit
Fig. 21.2 Representative
trauma bay. (London Health
Sciences Center/Western
University)
POCUSN2EM/GSx
N3
RT AP
Patient
TTL
Monitor
N1
MSK
Rapid
Transfuser
EDT
DIT
Trauma Team Function
Above all else, the Trauma Team must function as a team.
During the resuscitation of a severely injured trauma
patient, a large amount of information is rapidly gathered
about the patient’s injuries and physiologic condition, and
management decisions are similarly rapidly made based
on this information, often in a near-simultaneous fashion.
The presence of a team allows multiple actions to be
accomplished at once compared with a serial or vertical
approach required when only one physician is available to
treat such a patient. This departure from primary-care
emergency care provision in a small hospital is important
to note.
To function properly as a team, the team needs clear leadership. All information must be passed to the TTL and all
high-level decisions must be made by the TTL; otherwise,
the Team function becomes chaotic. For example, if only one
nurse is available, and both the anesthesia resident and the
orthopedic residents are demanding nursing assistance for
procedures (arterial catheters versus splints), the requests
should go through the TTL, and the TTL must prioritize the
order of work and decisively delegate the nurse to one or the
other resident’s aid.
Ideal destinations after leaving the Trauma Bay are: the
OR, the angiography suite, the ICU, or the Trauma Ward.
However, if their condition allows, many patients may be
required to return to the ED while awaiting bed availabil-
168
E. Walser et al.
ity. Many trauma centers have time-driven goals to measure delays in care and time to denitive investigations/
treatment. Commonly cited time goals include: handover
(< 60s), primary survey (< 5min), CT scan (< 15min),
admission/operating room (< 1h) [42]. Reviewing these
metrics on a regular basis can identify opportunities for
improvement.
Summary
The optimal care of the severely injured trauma patient is
predicated on the seamless function of a multidisciplinary
Trauma Team under the effective leadership of an expert
trauma clinician. Team and venue preparation are key components for success, and attention to the appropriate training—including education, simulation, and quality
improvement processes—will allow a Trauma Team to excel
in its care for these patients.
Key Points
• Treatment of a severely injured trauma patient is a
complex process.
• Optimal resuscitation is best accomplished with a
multidisciplinary team.
• Team function is dependent on technical as well as
non-technical skills.
• To optimize team function, it must be practiced.
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Interprofessional Team Roles
ElaineSigalet andMiretteDubé
22
Trauma patients are complex. Rapid assessment and surgical
intervention of seriously injured trauma patients can inuence the patient’s outcome: morbidity and mortality [1]. To
optimize outcomes in this cohort of patients, it is important
to have a highly trained team of experts who can be rapidly
assembled to ensure these patients get “effective” and “timecritical” care [2]. This team of professionals is called a
trauma team (TT).
Membership of a TT can vary nationally and internationally [3]. Membership can depend on the level of trauma center, an institution’s resources, professional practice roles, and
the practice model. According to the Advanced Trauma Life
Support Course (ATLS), membership should include a team
leader, usually an Emergency (EM) physician or trauma surgeon, an airway specialist, a circulating nurse and physician,
a scribe or documenter (nurse), and a social worker. In our
experience, it is helpful to have an extra nurse assigned to
medications, a dedicated porter, and unit clerk to facilitate
the transfer of information and resources as needed. In North
America, the respiratory therapist is the airway specialist.
The addition of a nurse practitioner is becoming more common especially in smaller trauma centers. With Pediatric
Trauma, depending on the level of consciousness, it may be
helpful to have a child life specialist. Today, regardless of the
profession, TT members are expected to complete advanced
certication in courses such as the Advanced Cardiac Life
Support Course (ACLS) and Pediatric Advance Life Support
Course (PALS). Furthermore, nurses are often required to
complete additional courses like the Trauma Nursing Core
Course (TNCC), the Advance Trauma Care Nursing Course
(ATCN), the Certied Emergency Nurse (CEN), and the
E. Sigalet (*)
Founding Partner Healthcare Systems Simulation International Inc,
Adjunct Assistant Professor, Department of Community Health
Sciences, University of Calgary, Calgary, AB, Canada
M. Dubé
Healthcare Systems Simulation International Inc.,
Cochrane, AB, Canada
e-mail: Mirette@HealthcareSSI.com
Emergency Nursing Pediatric Course (ENPC). Specic
requirement for trauma team nurses varies by institution,
organization, and level of trauma center. Respiratory therapists are often regulated and licensed and can hold a variety
of professional designations or titles such as a respiratory
therapist (RT), registered respiratory therapist (RRT), respiratory care practitioner (RCP), and or anesthesia or advanced
practice respiratory therapist (APRT) [4]. Where there is no
integration of the profession in critical care settings, this role
may be carried out by other experienced team members.
Regardless of professional designation, nurses and respiratory therapists are expected to recertify in the advanced
courses as dictated by the course, licensing body, and/or
organization. The concept of effective teamwork is a core
element in all these courses, yet practice is still frequently
restricted to intraprofessional practice often because of
course logistics and the clinical demands. This underpins the
need for incorporating simulation as a platform for streamlining the interprofessional task interdependence needed to
optimize “time-critical” assessment and intervention with
seriously injured trauma patients [5]
Effective and time-critical care is optimized when team
members can complete the taskwork in their role competently and condently to reduce the time to denitive care
[1, 3]. Honing task interdependence, the completion of several tasks simultaneously or in a horizontal fashion is optimized when team members have opportunities to practice
together. The interdependence of taskwork is also referred
to as teamwork. The outcome of teamwork is often referred
to as team performance [6]. Simulation creates a platform
for deliberate practice. Providing team members with this
opportunity is critical. Team members should be given
opportunities to practice task interdependence without any
risk to the real trauma patient. Research suggests teams who
work together frequently, without changes in membership,
are more effective [7]. Simulation as a training platform for
postgraduates has been shown to decrease the time to critical operations for trauma patients [8]. Teams who practice
together learn with each other, about each other, and from
© Springer Nature Switzerland AG 2025
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E. Sigalet and M. Dubé
each other to optimize efciency and quality in the care [6,
9, 10]. In care processes where emotion plays a role, delib-
erate practice becomes even more important. With the serious nature of injuries in the trauma patient and the risk of
exsanguinating, time pressure to perform competently in
roles becomes a source of emotion for many team members.
Emotion can interfere with how we store, process, and
retrieve information. Illeris refers to this as the tension triangle [11]. Our knowledge and skills, and our emotion is
dynamic and differs for each team member. When a team
member is functioning with a high emotional load, it may be
difcult for them to retrieve and apply information in the
moment. Most professionals will recognize a time when this
happened to them. This can lead to feelings of shame, perceived incompetence, and perceptions of feeling judged,
which can impede the success of the team. This has been the
impetus behind the development and use of cognitive aids in
addition to engaging in simulated deliberate practice. This is
real and a vulnerability associated with being human.
Preventing these circumstances is fueled by establishing
strong team skills and a sense of psychological safety among
team membership. Psychological safety is the internal feeling team members have, but rarely express in front of colleagues, especially if they perceive judgment, or there is an
explicit power gradient [12].
Teamwork skills are underpinned by communication,
coordination, and collaboration to ensure role clarity, effective leadership, closed-loop communication, situational
awareness, mutual support, and effective resource utilization [2, 6]. Communication errors inclusive of missing
information play a key role in hospital deaths [13].
According to the joint commission, 66% of in-hospital
deaths are attributed to communication errors, and this can
amount to up to 10% of seriously injured trauma patients
who may have presented with survivable injuries [13].
These skills, in addition to a sense of psychological safety,
are improved through opportunities for deliberate practice.
It provides opportunities for team members to engage in
care process discussions using teamwork skills and ask for
help when in doubt without feeling judged with effective
facilitation of the simulation. Teamwork skills create a common language and expectation for membership task interdependence. Today, in most undergraduate education and
training programs, students are introduced to these concepts, and in many programs, they have had opportunities
for application in simulation. They are developed in further
postgraduate opportunities in the real clinical practice contexts and in simulation.
To appreciate the dynamics within the TT membership, it
is helpful to reinforce the concept of inclusive leadership.
Inclusive leadership is a style developed to impart psychological safety amongst team members. With this style, leaders encourage team members to ask questions and support
decision- making, making it explicit that they will not be
judged [14]. An inclusive leader recognizes the vulnerability
associated with our human nature and calls on team members to work together using established teamwork skills to
ensure the care process is appropriate and timely. As already
stated, the respiratory therapy role and nursing roles are vital
to effective team performance. Each role has specic taskwork, which we will detail below.
Respiratory therapists are often required to cover large
emergency departments including all incoming trauma
admissions autonomously within their role. In smaller hospitals, there may only be one or two therapists working at a
time for the entire hospital. This requires the RRT to maintain situational awareness and coordination with other team
members to ensure resources are balanced for patients
requiring acute respiratory care. During trauma admission,
the respiratory therapist often assumes a position at the head
of the bed near the airway and can be called upon to manage
many different tasks in trauma. During a trauma admission,
the RRT will rapidly assess and manage the immediate respiratory and airway needs alongside the trauma or emergency
designated physician. The RRT specializes in advanced airway management, including intubation and mechanical ventilation strategies. Their expertise includes the initiation,
maintenance, and discontinuation of mechanical ventilation,
as well as the administration of oxygen (dry and heated
humidication systems) and other aerosol therapies. They
are often responsible for the administration of medical gases
such as Heliox, inhaled Nitric Oxide, and Epoprostenol, a
pulmonary vasodilator [15]. They specialize in difcult airway manipulation and capture techniques. In some situations, and centers, RRTS may be the assistant to the person
intubating, and in others, they may be designated to perform
the intubation [15]. Regardless of who performs the intubation, the RRT’s expertise is critical to locating, preparing,
and inserting all airway devices such as video laryngoscopy
and alternative airways. During intubation, an RRT prompts
and facilitates plans for the intubation; whether this is
through following a specied airway management/intubation team brief or checklist that exists in a center, or through
ensuring a clear intubation plan A, B, and C is established in
advance with the team. These airway management team
briengs ensure strategies, equipment, and human resources
are discussed should an airway attempt become difcult.
This enables anticipation and planning and allows opportunity for team suggestions. Another responsibility in this role
is to align optimal ventilation strategies to the patient condition (e.g., blood gas analysis, work of breathing, pulmonary
mechanics) and monitor physiologic response to the changes
made while clearly communicating these to the interprofessional team. It is critical that the RRT and RN communicate
any changes occurring, as one change to mechanical ventilation parameters or medication administration, for example,