Thursday, December 8, 2016

From Chaos to Clarity: Leadership in the Resuscitation Bay

Author: Mary Haas, MD
AAEM/RSA President '16-'17
Originally Published: Common Sense November/December 2016

You are managing a busy emergency department, when you hear via the overhead paging system that a new patient has arrived in your resuscitation bay. You scurry from the farthest corner of your department, where you were evaluating a patient with multiple chronic medical problems and multiple complaints. As you book it to the resuscitation bay, you carry the weight of several sick patients you are managing and the knowledge of several on stretchers waiting to be seen, not to mention the full waiting room. You arrive at the resuscitation bay, where a group of people are bustling around as if a storm is about to hit. You see the ambulance pull up to the doorway with lights flashing. In this moment, as leader of the resuscitation, you have the responsibility to transform chaos into clarity.

As I transition into my senior year of residency, this common scenario challenges me to reflect on and improve my leadership and communication skills. What makes a physician a good leader in the resuscitation bay?

Be calm.
Watching the physicians I most respect and admire in the resuscitation bay, I’ve realized the number one characteristic of an excellent leader is the ability to remain calm. The leader’s attitude and demeanor set the tone for the entire room, and a composed demeanor calms the environment and allows the leader to maintain control of the situation. Remaining calm eases the surge of adrenaline that accompanies the management of a crashing patient, allows one to think clearly and see the big picture, and leads to a safer and better resuscitation.

Along these lines, employing “noise discipline” to keep the room quiet will improve the team’s overall ability to focus and communicate. A resuscitation often attracts a crowd; as team leader it is important to ensure that only those who are actively participating in the care of the patient and contributing to the work of the team remain present.

Brief the team.
Having a few minutes after the notification of a critically ill patient's impending arrival, to gather the team and get everyone on the same page, is an opportunity to be seized. This precious time can have a hugely positive impact on the flow and success of a resuscitation. Take this time to introduce all members of the team; clearly delineate roles; prepare for procedures by having the necessary equipment handy; and create a shared mental model of the patient’s current status, plan, and anticipated disposition. This time also allows the team to ask questions. It is during this time that I reiterate to my team that we will maintain a calm and quiet environment.

Be clear and decisive.
The team leader’s role is to step back and monitor the “big picture,” to ensure the appropriate order of interventions and their correct completion. To be an effective leader, it is critical that the physician is clear and decisive when communicating orders to the team. This is where closed loop communication comes into play, allowing the sender to know that the request has been heard and the receiver to clarify and confirm. When asking that something be done, make direct eye contact, state the name of the person you talking to, and be as specific as possible. For instance: “Jim, please place a second large-bore IV” is better than “can someone place a second IV?” Also, when requesting that a medication be administered, make sure to clarify the dosage and route. For instance: “Karen, please give 1 gram of calcium chloride via the femoral line?”

After every resuscitation, make an effort to gather your team and debrief. What went well? What could have gone better? This may only take a few minutes of your time, but will bring you closer with your team and improve future resuscitations. It will also help you grow as a leader and show your team that you care about their feedback. Debriefing can also help the group cope with a difficult outcome.

Ultimately, the best way to improve one’s leadership skills in the resuscitation bay is to practice, reflect, and seek feedback. Observing my role models run resuscitations has also helped me to identify and mimic behaviors that lead to better team dynamics and better patient care. For many of us, it was the challenge of caring for the critically ill patient that drew us to emergency medicine. Mastering these skills helps us find satisfaction and meaning in our work.

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