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22
B. Hunter and K. DeanGubler
Clear, concise, accurate information needs to be relayed
through multiple sources. It needs to remain unadulterated
and precise. Problems in conveyance can arise anywhere in
the management of trauma including faulty medical devices,
communications equipment disturbances, interpersonal miscommunication, and so forth. Once information is received it
needs to be processed and communicated to the trauma team
by the team leader in a precise and concise manner. This
communication allows for transparency and clarity around
the care plan. It allows team members to stay involved and
promotes collaboration and creative thinking. It allows team
members to employ their own OODA loop.
Orient
Once an individual has received information, it is necessary
to process the information and organize it based on relevancy. Essentially, the information needs to be ltered. In the
inundation of input, look for the data that helps you to formulate a course of action. Again, the analogy of aerial combat. The color of the sky is probably not as important as
airspeed, altitude, or enemy location. All of that information
is available, but which is most benecial? It may be helpful
to ask some clarifying questions.
Boyd said:
The second O, orientation—as the repository of our genetic heritage, cultural tradition, and previous experiences—is the most
important part of the O-O-D-A loop since it shapes the way we
observe, the way we decide, the way we act [10].
Because of the multidisciplinary aspect of trauma care,
there is the pitfall and high likelihood of multiple opinions
and miscommunications occurring at this point. Situations
can become complex when multiple perspectives are derived
from the same objective information.
Consider, for example, hemodynamics. The average blood
pressure for a newborn is 64/41 and 95/58in a 2-year- old. For
a practicing pediatrician, these numbers would be appropriate.
In the trauma patient, however, these numbers would be alarming and may be indicative of poor prognosis. Context, background, perspective, and training all become potential points
of division and can undermine team dynamics.
To mitigate inefciencies and bolster effectiveness during
this stage, simulation scenarios in conjunction with team
building exercises are often employed. However, it is still
important to realize the potential for inadequacies.
Decide andAct
What am I missing?
What are the trends?
What else do I need to make a decision?
In addition to ltering information, it is important to know
that the orientation step of the OODA loop is the most subjective. During the observe phase, obtaining information is
paramount. This is an objective endeavor. How we perceive
information, however, varies wildly. In a study comparing
surgeons, non-trauma to trauma, there were eight categories
that were identied as “educational dilemmas” [9]. The areas
of concern were:
1. Thinking physiologically
2. Damage control surgery
3. Priorities and time management
4. Impact of environment
5. Managing limited resources
6. Lack of general medical skills
7. Different cultural behavior
8. Ethical issues
Several of these categories are the result of past experiences. Our personal experiences, in large part, shape how we
lter and eventually apply information. Because of this, the
orient step is the point in the OODA loop where personal
biases can cloud judgement and undermine our team efforts.
When the information has been processed and ltered, the
next step of the OODA loop is to decide and act. Decisions
need to weigh the anticipated result with the associated risks.
This balance should help guide the course of care. To assist
with this, specic algorithms can become effective. These specic models will outline a step-by-step guide for the course of
treatment. Some examples that include CPR (cardiopulmonary resuscitation), ATLS (Advanced Trauma Life Support),
ACLS (Advanced Cardiac Life Support), PALS (Pediatric
Advance Life Support), institution specic protocols, etc.
Once a decision has been made, the team lead must communicate that decision to the team and to delegate responsibilities. The team lead’s responsibility is continual, just like
the OODA model, and comprises synthesizing the information, devising a plan of action, and motivating the team to
follow through.
It is important to recognize that the OODA loop does not
stop at this point. The stages that have been described occur
frequently and often through the entire process and are consistently re-examined as new and pertinent information arrives.
Modication of the management of the critically injured
should be anticipated and embraced as more information
becomes available and care progresses. It is important for the
team lead to evaluate the effectiveness of the clinical evaluation and clinical interventions as more information becomes
available. Further decisions and actions depend this ability to
be exible and responsive to new information.
4 Trauma Team Development: Leadership andCollaboration
23
Conclusion
Not every team is great. There can be problems with management, teamwork, logistics, resources, or communication.
Extraordinary teams possess not only technical competence,
but members also have the emotional maturity to know when
to lead and follow. They know how to communicate, how to
relay reliable information, and know that ultimate decision
making is the responsibility of the team leader.
In support of their team, the team leader recognizes and
employs effectively CRM.This responsibility is crucial to team
success and is an inherent part of the team leader’s role. By
managing resources, promoting development, providing guidance, and employing policy the trauma team leader enables
their team to perform at high levels and as a cohesive unit. This
synergistic unity promotes open communication, information
sharing, and exibility during acute medical care. The OODA
loop is a continuous cycle that can only be effective when the
trauma team shares information openly and freely. Engaging in
active CRM and the OODA loop utilization, trauma teams can
be what patients and their families deserve.
References
1. Part 1: A brief history of trauma systems. American College of
Surgeons. https://www.facs.org/quality- programs/trauma/tqp/
systems- programs/trauma- series/part- i. Accessed 22 Dec 2020.
2. Part 2: Why the U.S. trauma system needs a robust civilian-military
partnership. American College of Surgeons. https://www.facs.org/
quality- programs/trauma/tqp/systems- programs/trauma- series/
part- ii. Accessed 22 Dec 2020.
3. Part 3: Sixty-year military-civilian partnership serves as a model for
the national trauma system. American College of Surgeons. https://
www.facs.org/quality- programs/trauma/tqp/systems- programs/
trauma- series/part- iii. Accessed 22 Dec 2020.
4. Trauma Center Levels Explained. American Trauma Society.
https://www.amtrauma.org/page/TraumaLevels. Accessed 22 Dec
2020.
5. Trauma Centers. American College of Surgeons. https://www.facs.
org/search/trauma- centers. Accessed 22 Dec 2020.
6. Joshi N. Crisis Resource Management. ALiEM. http://www.
aliem.com/crisis- resource- management/. Published 12 Nov 2016.
Accessed 22 Dec 2020.
7. Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010;105(1):3–6. https://doi.
org/10.1093/bja/aeq124.
8. Burden A.High-delity simulation education and crisis resource
management. Clinical Key. https://www- clinicalkey- com.proxy.
rvu.edu/. Published 1 Dec 2020. Accessed 22 Dec 2020.
9. Sonesson L, Boffard K, Lundberg L, Rydmark M, Karlgren
K. Decision-making in management of the complex trauma
patient: changing the mindset of the non-trauma surgeon. World
J Surg. 2018;42(8):2392. https://search- ebscohost- com.proxy.rvu.
edu/login.aspx?direct=true&db=edb&AN=130602864&site=edslive&scope=site. Accessed 22 Dec 2020
10. Boyd J. Organic design for command and control. Address presented at the: May 1987. http://publiclibrariesonline.org/2018/05/
observation- orientation- decision- action- applying- the- ooda- loopconcept- to- libraries/. Accessed 22 Dec 2020.
Improving Human Factors, Teamwork,
andCommunication inTrauma Care
PeterG.Brindley andJocelynM.Slemko
5
Introduction: Why Does Teamwork Matter?
The real problem of humanity is the following: we have paleolithic emotions; medieval institutions; and god-like technology.
E.O. Wilson. Biologist
Talent wins games, but teamwork, and intelligence wins
championships
Michael Jordan. Basketball God
Introduction
While accepting that aviation will never be exactly the same
as trauma medicine, even the greatest cynic should accept
that other high-stakes, high-reliability industries still offer
numerous oven-ready ideas. Hence, this chapter will cover
aviation’s crew resource management and how it dovetails
with medicine’s crisis resource management. We hope to
offer a concise primer, while evergreening a topic (CRM)
that needs to be further developed, and even more widely
understood. Regardless, the best trauma team members will
welcome practical insights and reminders, no matter the
source or repetition. Excellence does not happen by accident.
It starts with the humility to (over)learn from others and a
commitment to constant self-reection and iterative
improvement.
The literature has now made it abundantly clear that inadequate teamwork and inadequate communication are among
the most common reasons for preventable error in both aviation and acute care medicine [1–6]. The debate is over, and
now the issue is how to operationalize what we already know.
For example, in trauma care, there is an increasing acceptance of the importance of simulation training, and the need
P. G. Brindley (*) · J. M. Slemko
Department of Critical Care Medicine, University of Alberta
Hospital, Edmonton, AB, Canada
e-mail: Peter.Brindley@albertahealthservices.ca;
Jocelyn.slemko@albertahealthservices.ca
Table 5.1 Practical strategies to improve team work in a medical
crisis
Team factor Recommendation
Climate and culture More “we,” less “me”
Mutual respect; calm and decisive
Hierarchy still has a role
“What” is right, not “who” is right
Establish structure Assign roles
Assign responsibilities
Establish 3 priorities
Communicate throughout
Shared mental model Ensure all on ‘same page’
Invite input when possible
Share the priorities; update prn
Set the emotions of the team
Cross monitor Monitor performance
Monitor workload
Flatten hierarchy
Encourage feedback
Maintain resilience Routine practice sessions
Request feedback
Encourage debrief
Provide time for casual interaction
to deliberately address human factors and team dynamics,
but we need to go further [1, 2].
Our medical profession is overdue in terms of embracing
a culture of safety and self-reection and peer-review. We
have also yet to accept how much can be achieved from the
aggregation of marginal gains and empowering all members
of the healthcare team, not just senior administrators. Even if
medicine does not equal aviation, the latter offers translatable strategies regarding how to promote a “science of reducing complexity,” “science of team performance,” and a
“science of safety” (See summary Tables 5.1 and 5.2).
As has been outlined in numerous medical lectures, the
largest aviation disaster occurred in 1977 when ights KLM
4805 and Pan Am 1736 collided. Five hundred and eightythree died. Investigators concluded that not only was the
accident wholly preventable, but that a major cause was
because the crews had “failed to take the time to become a
team.” [1] In a similar vein, evidence shows that fewer planes
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_5
25
26
P. G. Brindley and J. M. Slemko
Table 5.2 Practical strategies to improve verbal communication in a
medical crisis
Perform regular simulation exercises
Practice active-listening
Model “transmitter-oriented language”
Ban “mitigating language”
Cite names; be Clear/concise; Close the loop (3 C’s of
Communication)
Structure communication using “SBAR” and “repeat-backs”
“Call out” when signicant changes occur
Practice “escalating assertiveness”
Avoid “somebody”/“anybody” comments
Respect communication “sterility”; control interruptions
crash when the co-pilot is ying [7]. There are many reasons
why, but part of it is because, rstly, the senior pilot is
unafraid to speak up, and, secondly, because the subordinate
is now actively involved [7]. In other words, an ad hoc team
is formed, and that team has larger mental and physical
capacity than previously existed. Evidence suggests the same
for acute care medicine [2]. In short, trauma training needs
more “we” and less “me” [2].
Our profession has been slower than aviation to realize
that team skills are not innate and therefore cannot be left to
chance or intuition. In addition, these are non-technical
skills, require novel approaches, and must be practiced. This
is why simulation is not a luxury but rather a part of core
business. As will be outlined, team skills encompass effective communication; adaptability; compensatory behavior;
mutual monitoring and the ability to give and receive feedback [2]. In short, modern trauma care is as much about
“team-dexterity” and “verbal dexterity” (see below) as it is
about traditional factual knowledge or procedural skill.
Another readily applicable aviation example is the 1935
crash of the B17 bomber during a test ight; when it was
lamented that “the modern plane is just too much for one
man to y.” [1]. Similarly, the complexity of trauma-care
makes the modern patient simply too much for one clinician
to manage. After all, the modern critical care unit patient has
been estimated to require approximately 180 steps perpatient per-day [1]. Regardless of the exact number, clearly
such complexity exceeds even the most capable individual.
Therefore, it is not hyperbolic to argue that without effective
teamwork, high-quality trauma care is largely impossible. In
short, trauma care truly is a team sport [2].
What Does It Take toCreate aTeam?
Teamwork, which can be dened as “cooperative efforts to
achieve a common goal,” is more than just subordinates
doing as the leader tells them [2]. Instead, it is about maximizing the mental and physical problem-solving capabilities, such that the sum exceeds the parts [2]. Additionally,
task demands (rescuing the patient) and social demands
(running the team) have to work in parallel [2, 8]. In other
words, there is a difference between taskwork (getting nite
things done) and teamwork (nurturing a group of people so
that they can achieve many things). We need to turn individuals into team players, or else the team fails, and the patient
pays the price. Individual team members will not share their
abilities unless they feel safe to do so [2]. This does not mean
that we no longer need a leader and leadership: it means that
we cannot create the teams that we want unless we create the
culture that we need [8].
Team Culture: Not Just Leaders; Followers Too
Most people accept that culture matters, but unfortunately,
“culture” is rarely dened or measured. As such, “culture
change” seems to be little more than a buzzword than an
overdue imperative. This chapter does not allow for an indepth discussion, but the work of Dutch Psychologist, Geert
Hofstede, offers a good starting point [9]. His group outlined
six indices of culture, which include: Power Distance Index
(i.e., how the powerful and less powerful accept their status);
Individualism (i.e., loyalty versus everyone for themselves);
Masculinity vs Femininity (i.e., money-focus; selfcenteredness); Uncertainty Avoidance (i.e., comfort with
uncertainty; reliance on rules vs style); Long-Term
Orientation (i.e. persistence, and the importance of shame),
and Indulgence vs Restraint (i.e., individual freedom vs societal norms).
Culture is a complex whole that encompasses the knowledge, beliefs, customs, and habits of a group, not just the
habits and beliefs of an individual. Group culture has a powerful inuence upon behaviors, attitudes, and action.
Medicine has had a laudable culture that emphasizes patient
ownership and self-reliance. The downside is that this can
promote the individual agenda over team cohesion. Similarly,
traditionally, we have also assumed that success results from
individual efforts (and failure from individual shortcomings), ignoring the contributions of all team members and the
environment. Accordingly, remedies have previously focused
on individual competence or blame. It’s time to update.
A thriving, effective medical culture requires commit-
ment to hard work over years rather than the typical
trauma timescale, namely hours or even less. We must
ensure that empathy is cultivated and shared, and work-
place complacency (or toxicity) is not tolerated.
Buzzwords aside, we really do need to create and nourish
a safe work environment. Teams absolutely still need
structure and hierarchy, but the skill is to simultaneously
ensure that we leverage everybody’s knowledge and skills
[10]. It is important to understanding that those actively
talking (i.e., resuscitating by voice) are no more important
5 Improving Human Factors, Teamwork, andCommunication inTrauma Care
27
than those actively listening [10]. Team leaders may be
largely responsible for setting the dynamic, but, importantly, we all own and affect culture.
Skilled leadership improves team performance, satisfaction, and efciency [11]. However, just like culture, the
denition of a good leader is difcult. An effective leader
knows when to be hands-on (explicit leadership) and
when to step back and delegate (implicit leadership) [10].
Leadership requires skill and experience and cannot
always be intuited. Leaders must simultaneously earn the
team’s trust, present an acceptable shared mental model,
centralize information ow, coordinate tasks, and overcome emotions (their own and others’) [12]. Through
managing and monitoring the overall situation, they
accept disproportionate responsibility (i.e., including
when they are not at fault). They step up and get their
hands dirty when required. Leaders also teach, mentor,
and model a standard for the whole team [11]. This is why
hierarchy matters—you earn the right to lead; it isn’t just
awarded on day one. It is also why leadership is difcult
and followers should help leaders and forgive occasional
failings. Leadership traits and skills are discussed further
in Chap. 20.
Much of the medical literature focusses on the qualities of
an effective leader, but there is a paucity of discussion on
what makes an excellent follower. To date, there are 60 publications on leadership for every one publication on followership [13]. Self-identifying as a “follower” (i.e., a relative
subordinate) is still associated with signicant stigma, even
though 85% of healthcare workers are better understood to
be followers, and the system simply could not function without them. Once again, these skills should be taught and
highly valued. In short, followership is an advanced and
impressive skill.
Effective followers have capacity to step up when required
and do not take it personally when they need to step back.
They are able to self-manage and use their emotional intelligence to size up when and what they should contribute
[10].
Members of the trauma team oscillate between assuming
leadership and followership roles. Therefore, one should
simply talk about high functioning team members, who, in
turn, are those dexterous enough to adapt to what (rather than
who) is right. Effective leaders and followers also cross monitor, meaning that while they manage themselves, they also
remain vigilant to the needs of others. Every good trauma
team member has a “sixth sense,” where you size up a situation and decide to step up or step back, depending on what
will best serve the patient and team.
Resuscitations often require sub-teams, while each team
member maintains a global perspective and sub-teams divide
up the work and can thereby narrow their focus—to minimize task overload and maximize cognitive ofoad [14].
Examples include an airway team or vascular access team.
The goal is to divide the resuscitation into manageable
chunks and enable the leader to maintain a more supervisory
role, or “thousand-foot view.” [14] In nature, there are two
types of attentiveness. System-1 is a focused spotlight gaze,
such as when a predator focuses on only what truly matters,
namely catching prey. System-2 involves scanning from
stimulus to stimulus. In nature, the potential prey must avoid
xating on one spot and instead adjust their attention constantly in order to avoid being eaten [11].
The most common team failings (and therefore the areas
on which to focus our resources and energies) are the inability to assign roles and responsibilities; to hold team members
to account; to advocate a position or a corrective action; to
use check-backs (i.e., “closed-loop communication”); to
seek usable information (as opposed to just “data”); to prioritize tasks; and to cross-monitor other team members [2]. In
short, it should be clear why a team of experts is not the same
as an expert team [2].
Teamwork: Good andBad
Teamwork is probably the best way to mitigate task-overload
and xation errors. However, not all teamwork is inherently
good. As a result, psychology also offers useful cautionary
tales for the modern trauma team. Zimbardo’s infamous
Stanford Prison experiment (which had graduate students
assume the roles of prisoners and prison guards) demonstrates how easily we can be made to assume roles even
when not benecial. Even though supposedly play-acting,
the students quickly formed into two teams, with one becoming excessively unruly (the prisoners) and the other excessively sadistic (the guards). In a similar vein, Stanley
Milgram’s work (where he was able to get people to administer electric shocks to others) further demonstrates our propensity toward blind obedience [15]. Solomon Asch’s
experiments (where he could get experts to give incorrect
answers just by having other confederates answer incorrectly
beforehand) show how easily we can be made to do things
that we know are wrong. Importantly, in Asch’s experiments
there was no overt coercion, merely the power of embarrassment and social conformity [15].
The apparent irrationality of modern humans and their
blind spots is tough for some professionals to accept [8].
However, humans have evolved as social beings and are
therefore highly susceptible to social pressures [2, 8].
Regardless, it should not be surprising that we resort to
behaviors that have worked well for most of our evolutionary
past, especially during crises [8]. Moreover, we all have
biases, and while we may be adept at seeing them in others,
we are less likely to see them in ourselves. Regardless, good
team leaders know to capitalize on the best of our primitive
28
P. G. Brindley and J. M. Slemko
crisis behavior and mitigate against innate shortcomings. For
example, good leaders can capitalize on our propensity to
obedience during a crisis. At the same time, good team leaders realize that too much hierarchy will suppress the team’s
larger cognitive capacity [8].
Insightful team leaders should know that once a majority of team members have formed an opinion, they usually
stick with it despite contradictory information [2]. This is
done subconsciously to reduce a sense of isolation and
“cognitive dissonance” (the discomfort that humans have
with holding two or more contradictory ideas simultaneously) [15]. As a result, a good team leader will deliberately and routinely challenge assumptions (why are you so
certain this is hemorrhagic shock?). Similarly, “group
think” means that teams may follow the majority opinion
rather than the rational argument (“if we all agree then we
can’t be wrong”) [2, 15]. As a result, the effective team
leader will force the team to seek out contradictory information (“I still want to see that ECG before we take this
patient to the operating room”). Interestingly, teams can
also amplify individual behavior. For example, groups tend
toward greater risk if an individual’s initial tendency was to
be risky and toward more caution if individuals were risk
averse [2, 15]. Team behavior can (and must) be managed
and is a key leadership skill that can be taught.
Team Leadership 101: TheShared Mental
Model
Leadership includes providing structure to chaos, and organization where previously there was none [8]. A key strategy
is the “shared mental model” (a common understanding, or,
in colloquial terms, a sense that everyone is “on the same
page”) [2]. This helps to form a task-focused (rather than
power-focused or ego-focused) team as well as a structure
that prioritizes duties, manages information, establishes
roles, stabilizes emotions, and can build condence [2]. If
time allows, then the team leader should invite members to
suggest a mental model (“what do you think?, what should
we do?”). After all, diverse inputs can provide the team with
a more comprehensive view [2, 8]. However, under time
pressure, the leader has to rapidly establish a reasonable
mental model that members will support (“I believe its hemorrhagic shock, unless I’m missing something please do the
following”) [3]. Studies have shown that the best situational
awareness and the shortest reaction time come from practice
and prior exposure [8]. In this way, simulation is a great way
to develop team “reexes” and for leaders to learn the power
of the “shared mental model.”
The greater the overlap in shared mental models, the more
likely that team members will predict, adapt, and coordinate—even if dealing with stress or novelty [2]. It is also
essential to regularly update the shared mental model (“okay,
the airway is secured; our next priority is…”) and to ensure
that it still makes sense as new knowledge comes to light (“I
now have an ECG that shows ST elevation—please listen up
because things have changed”). Task assignment is usually
specied by profession (e.g., anesthetists intubate and surgeons operate) [2]. Therefore, this does not usually need to
be negotiated in the mental model. However, if there is confusion (i.e., both the anesthetist and surgeon could insert central lines), then the good leader predicts that it may cause
confusion and hence that it needs to be explicitly stated (“Dr
Smith, you intubate, Dr Jones you do lines”). In short, the
mental model must be clear, proactive, exible, and shared.
Say What YouMean andMean What YouSay
Mounting evidence shows that ineffective communication
during an acute medical crisis is one of the commonest reasons for preventable medical error and preventable death [3,
7, 16]. This should not be a surprise, after all we have long
known that poor cockpit communication—especially
between junior and senior crew—is one of the commonest
reasons why mechanically-sound planes crash [3, 7, 16]. It is
also time to understand that our “verbal dexterity” is every
bit as important as factual knowledge or procedural dexterity
during a crisis [3]. Most of what follows is not native to medicine. It is, however, highly translatable to our reality.
Many shortfalls in communication can be summarized
using the following pithy quote by Rall and Gaba: “Meant is
not said; said is not heard; heard is not understood;
understood is not done.” [17]. However, it is also important
not to oversimplify something as complex as communication. For example, communication is far more than just talking. Communication aids task execution; enables information
exchange, and helps (or hinders) relationship building [2].
Communication is also more than just what is said. It also
includes how it is said and how it is understood [2]. As a
result, non-verbal communication (which includes posture,
facial expressions, gestures, and eye contact), as well as
para-verbal communication (which includes pacing, tone,
volume, and emphasis), is at least as important as verbal
communication [2, 16]. This is especially true when there is
incongruence between the words used and the facial expression or the tone [15]. As a result, while this section will present several practical verbal techniques (again borrowed from
aviation and adapted to medicine), we are only scratching the
surface. Readers are strongly encouraged to read more and to
realize that expertise in acute trauma means expertise in all
facets of crisis communication [2, 3, 16].
Flight investigators made a priority of attening the
authority gradient. [7] One way to do so is to mandate more
“horizontal communication” [7, 16]. This means that all
5 Improving Human Factors, Teamwork, andCommunication inTrauma Care
29
members of the team are authorized—in fact they are obligated—to speak up, and to do so clearly, regardless of rank
[7]. Moreover, aviation has mandated “transmitter orientated” communication (where it is the speaker’s responsibility to be understood) rather than “receiver orientated”
communication (where it is the listeners responsibility to
unravel what was meant) [7]. However, making communication more deliberate means that we also promote active
listening [2]. This requires that we conrm understanding
and demand clarication, regardless of seniority or embarrassment. [2, 4, 5] All team members take responsibility for
how messages are delivered, received, understood, and car-
as follows: Probing, Alerting, Challenging, and nally
Emergency [22]. Other constructs include up to six steps.
Regardless, the intention is to offer strategies from least to
most direct. For example, this includes the “hint” (e.g.,
“should things look like this?”); “preference” (e.g., “I would
suggest…”); “query” (e.g., “what do you think?”); “shared
suggestion” (e.g., “you and I could”); “statement” (e.g., “we
need to”) and “command” (e.g., “do this now!”). Of note,
those actively listening should also pick up on the escalating
urgency and react accordingly. It is worth re-emphasizing
that leaders understand that crisis communication is as much
about listening as talking.
ried out [2, 3, 8, 16].
and, if ignored, fail to escalate their assertiveness further [7].
On the other extreme, without instruction, senior team mem-
Crisis Communication 101
bers may rely too heavily upon blunt “commands.” [7]. This
style is certainly unequivocal and is needed when team mem-
A common feature following aviation crashes is black-box
silence during minutes prior to a crash. [3, 7] Similarly, ask
most nurses about the last bad resuscitation they witnessed,
and it is likely notable for the same thing: silence despite
chaos. Therefore, team members need to be taught strategies
regarding how to speak up [3, 7, 16]. Physicians may not
speak due to stress or uncertainty, or simply because they do
not have the usable lines [18]. For example, instead of
silence, we can teach the leader standardized verbal
responses. An example would be: “we still have no pulse…
what am I missing?” Another would be: “I am unclear what
happened before we arrived; who can summarize?” [3].
bers have repeatedly failed to appreciate the seriousness of a
situation. However, it can destroy the team structure if routinely used as the initial, or the only, communication style
[7]. With the same purpose in mind, aviation also teaches a
ve-step model of advocacy and conrmation [18]. The fol-
lowing includes aviation examples and medical corollaries:
Attention Getter (“Captain/Doctor”), State Your Concern
(“We’re low on fuel/the patient is hypotensive”), State the
Problem as You See It (“I don’t think we can land/I think we
need to operate now”), State a Solution (“Let’s re-route to a
closer airport/I’ll book the OR theatre”), Obtain Agreement
(“Okay, Captain/Doctor?”) [18].
Other team members need verbal strategies to become part
of the trauma team rapidly. An example could be “I am from
General Surgery; is there any job that needs doing?” Just as
teamwork does not come naturally, neither does crisis communication. Again, simulation is an ideal tool. It enables us
to discover what works and to master what are, after all, lifesaving skills.
The military and aviation have long used the SBAR acro-
nym (Situations, Background, Assessment,
Recommendation) in order to provide a recognizable structure to communication [3, 19]. While it may seem overly
formal—especially when team members are either familiar
with each other or if the problem is routine—it can offer a
very useful construct for junior staff and for unfamiliar situations [19]. A simple example could be: Situation: “this is
Dr X, I need your help right away”; Background: “he’s a 35
year old with a splenic injury”; Assessment: “he is still
hypotensive despite four units of blood.” Recommendation:
“You should review him now regarding need for surgery.”
In addition to getting aviators to speak up, they are also
taught how to be acknowledged and how to be taken seri-
cite names (to avoid diffusion of responsibility); that we
must be clear and concise (to avoid confusion); and most
importantly, that we must close-the-loop (to conrm that it
has been done) [3–5, 16, 18]. This means that we reinforce
our instructions by demanding verbal feedback. For example, we tell a specic person to intubate but also to tell us
when it is done (or to tell us the end tidal CO2). This also
means we do not just ask for two units of blood but rather
“Nurse, give two units of blood…and tell me the blood pressure when it is in” or “Jim, poke for an arterial blood gas…
and bring the result back to me.” In other words, there are
many ways to “close the loop,” but as a strategy it conrms
that the instruction was heard, understood, and done. A
potential additional C includes crowd control. This means
ensuring that there are enough people present (“we do not
have someone who can do a surgical airway, go and get me
Dr X”), or that we have the right people present (“please tell
me your role”), or that we do not have too many people present (“thank you for responding, but we need to clear out all
but the following people…”).
ously. Therefore, they learn how to use levels or grades of
assertiveness [2, 3, 7, 16, 18, 20–22]. For example, Robert
Besco’s iconic four-step P.A.C.E communication progresses
we alert the team whenever there are important changes
(“he’s starting to go back into ventricular brillation”) [18].
Without instruction, junior team members may only hint
Applying the “C’s of communication” mean that we must
Another strategy is the “call out.” [18]. This means that
30
P. G. Brindley and J. M. Slemko
Similarly, the “step back method” means we verbally force a
“time-out.” This compels the team to reassess their assumptions (“stop chest compressions, we need to know if we’re
still in asystole”). The “repeat back method” [18] provides a
safety check by repeating an order to conrm mutual understanding (“so was that one full milligram of epinephrine?”).
The “read back method” [18] means we conrm a verbal
order before processing it (“okay, so rst you want two units
of packed cells, then repeat a hemoglobin, then call you if it
has not increased”).
While team members must be encouraged to speak up,
they need to be taught how to make those inputs task-focused
and appropriately timed. If not, it can further exacerbate the
cacophony and chaos [2, 8]. Non-helpful interruptions are
considered such a safety hazard in aviation that they are now
addressed in this industry’s standard operating procedures.
The “Sterile Cockpit Rule” means that no non-operational
talk is allowed during critical phases such as taxi, take-off, or
landing [16, 23, 24]. Of note, it applies to all those in the
cockpit to enforce it, not just those currently talking. [16, 23,
24] We understand the need for microbiologic sterility in sur-
gery, so why not “communication sterility.”
The Sterile Cockpit Rule [23, 24] can be readily adapted
to medical practitioners during resuscitation [3, 8]. In lesscritical situations, we should conrm if others are able to
focus their attention (“I want your opinion, do you have two
full minutes?”) [3]. In more critical situations, we can
demand attention (“I need you to stop that conversation and
focus on this critically ill trauma patient”). A great example
comes from the everyday operating room: the anesthetist is
in his or her critical phase during induction and awakening.
Therefore, the surgeon must avoid unnecessary noise or distraction. Once the operation is underway, the surgeon is now
in his or her critical phase even if the anesthetist no longer is.
It is now just as important for the anesthetist to avoid unnecessary interruptions or disturbances of the surgeon. In other
words, all members are responsible for creating the right
environment so that the right team communication can be
leveraged to benet the patient [3, 16].
Ambiguous or non-committal speech (aka “mitigating
speech”) is common prior to airline crashes, as well as during medical crises [7]. This is why, during crises, we must
replace comments like “perhaps we need a surgeon,” or “we
should think about operating,” with “get me a surgeon” and
“we need to go to the operating theatre now.” Junior members (or those that feel “unsafe” in their role) may mitigate
speech to show deference when embarrassed or if unsure [2,
3]. Interestingly, if time permits, then “mitigating language”
can be harmless and may aid team building (“if you get a
moment could you help me with this patient?”). However, if
the wrong communication tool is used during a crisis, it can
be no less dangerous than the wrong surgical instrument. It is
about being as dexterous with your communication as with
your hands.
Over-cautious language is inappropriate during crises,
just as overly strident language can be inappropriate at less
critical times. Crisis communication should still be polite but
must be unambiguous (“Jessica, your next job is to intubate,
do it now, please”). Communication must also be addressed
to a specic person to avoid diffusion of responsibility [2, 4,
5]. This is why comments like “could someone” and “does
anybody” are inappropriate even if they are polite [2].
However, just as we need to control communication during a
crisis, we need to loosen the reigns once it has abated. As a
result, at other times we also need to promote more freeowing communication. This is essential for debrieng, conict management, and stress relief. In other words,
communication is also essential to keep the team resilient
ahead of the next crisis [2].
Conclusion
Despite a culture that typically trumps the individual, modern medicine (and especially acute care medicine) demands
teamwork and team communication. In addition, it requires
team leaders and followers who understand the basics of
human psychology, and how this can be utilized to the
patient’s benet. Practitioners, educators, and administrators
should agree that teamwork must not be assumed or left to
chance. Instead, teamwork should be deliberately taught,
routinely practiced, and reliably funded. We also need to
adapt, and then to freely share, the best strategies learned
from other high-stakes professions but also from each other.
The question is whether we have the requisite humility,
insight, common sense, and culture to evolve.
Key Points
• Non-technical skills likely have the greatest impact
upon patient safety and outcome.
• We must make a “science of reducing complexity”—
fortunately practical strategies can be taught.
• Teamwork is key to reducing chaos and
complexity.
• Communication is the key leadership skill.
• Good teamwork (and communication and followership) cannot (and need not) be left to chance.
5 Improving Human Factors, Teamwork, andCommunication inTrauma Care
31
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Introduction toLeadership:
Self- Awareness andSelf-Management
DavidKoltho andSandyWidder
6
Trauma resuscitations are a time of chaos, high emotions,
and multiple moving parts within the system. A trauma
leader needs to guide and act as an emotional compass keeping the team working in synergy and goal focussed. They
cannot rely on a single and linear style but need multiple
tools in their leadership toolbox to utilize based on the situation and emotional temperature of the team. This chapter will
provide the rst steps to building an accountable, authentic,
and grounded leader and bring greater success to your team.
Background
Trauma can be an environment of chaos. As such, meaningful leadership skills are required to deliver timely care and to
optimize outcomes. Resuscitating the trauma patients can be
demanding due to the concomitant stress of rescuing unstable multi-injured patients and directing the needs of the multidisciplinary team. Therefore, a leader must rst lead
themselves before they can effectively lead the team to success. Leadership is the most essential nontechnical skill for a
trauma team to be successful [1]. Furthermore, effective
leadership reinforces a culture of collaboration and teamwork within the trauma team [2].
A growing body of literature suggests that training
focused on leadership, team building, and team training is
greatly related to increased team coalition and improved success with outcomes. Thomas etal. studied pediatric residents
undertaking a common neonatal resuscitation program but
provided deliberate team training to only half. This single
intervention was associated with increased information sharing, inquiry, assertion, vigilance, and workload management.
D. Kolthoff (*)
Alberta Health Services, Edmonton, AB, Canada
e-mail: David.kolthoff@albertahealthservices.ca
S. Widder
University of Alberta, Edmonton, AB, Canada
e-mail: sandy.widder2@albertahealthservices.ca
Other studies have similarly concluded that leadership and
team structure improve team performance [3–6]. Accordingly,
courses such as Advanced Life Support and Pediatric
Advanced Life Support courses supplied by the American
Heart Association that historically were focused on factual
knowledge now included modules in leadership and teamwork [7].
Leadership Styles
Despite the multiple styles of leadership available within literature and the web, they can be grouped into three categories: empowering, directive or commanding, and passive. In
1939, psychologist Kurt Lewin led one of the most inuential leadership studies. Lewin studied school children and
placed them in three groups with an authoritarian (commanding), democratic (empowering), and laissez-faire (passive) leader (See Table 6.1). Lewin found three distinct
groups of behaviors based on the group the children were
placed in. The children were less creative in the authoritarian/commanding group due to the top-down approach, where
the leader is typically the most knowledgeable with little
input from the team or group. Lewin found the children in
the democratic group to be more empowered and creative,
with greater quality with their contributions but less productive than the authoritarian group. The laissez-faire leader was
found to be passive, less productive, and creative than the
other two groups but also created more demands on the
leader. They also showed an inability to work independently
and also demonstrated little cooperation with each other.
Subsequently, multiple studies have identied leadership
styles and dissected them further into more detail. Goleman
divided leadership into two distinct categories: resonant and
dissonant. He further dissected these two categories into
greater detailed styles: resonant styles-visionary, coaching,
afliative, and democratic. Dissonant styles- pacesetting and
commanding. The resonant styles create inspiration, creativity, and motivation where the dissonant styles share the same
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_6
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