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There’s no “I” in crisis

A physician-in-training on teamwork and trauma in the ER

medical team working under pressure
Image Credit: Alice Lee

When you’re a doctor, your signature scrawled at the bottom of a patient’s record assumes a lot of responsibility. It says that, no matter the outcome, you were responsible for making the final calls. This burden breeds two kinds of doctors: cautious and cowboy.

“Every attending [physician] measures risk differently. A really cautious attending will admit a patient to make sure they don’t have a heart attack a few hours later, but a cowboy doctor—which isn’t to say they’re reckless, just more assertive—will be quick to send someone home so we can serve more patients,” explains a bleary-eyed Matthew Rogers over video conference.

Now in his third year as an emergency department resident at Bellevue Hospital — a teaching hospital in New York and the largest public hospital in the United States — Rogers is in the midst of figuring out which kind of doctor he’s going to be. For now, he’s focused on learning how to lead a team, and make decisions, under a relentless firehose of pressure — a skill that takes anywhere between four to five years to fully develop.

“I’m lucky that right now I have a bit of a protective cushion with a senior resident and attending above me,” he says, “but I’ll probably be quite cautious my first year out as an official attending. Right now, I just keep thinking to myself: Okay, if I were the last person making this decision for this patient, what would I do? That’s when things start to feel really hairy.”

Fortunately, he’s got a few strategies under his belt.

 

Confidence (or at least the appearance of it) is key

Your confidence as a doctor has little to do with your ability to control your nerves under pressure, says Rogers. In fact, he says most ER staff tend to be fairly laid back. The real test is in your ability to command a team during the chaos of trauma.

In classroom simulations, Rogers struggles with juggling communications and corralling staff members during an emergency. “It’s a strange position to be in because on the one hand you’re still learning and on the other you have zero time to second-guess yourself,” he says, recalling one of his first simulations a few months ago. “Part of the role is speaking up and telling people to be quiet, people who are much more senior than you. That’s hard for me. I’m not used to telling people what to do all the time.”

 

“There’s a lot of noise, you wouldn’t believe how loud it gets, all these people are talking over each other. I have to come in and make it clear that I’m running the trauma. My job is to orchestrate: delegate roles, update everyone on new developments and where we’re at, and keep side communication to a minimum.”

 

Let everyone know who’s boss, literally

On the ER floor, the nature of shift work further complicates things. In a single eight, ten, or twelve hour shift, the entire emergency department staff can rotate multiple times. It’s not uncommon to have members on your team whom you’ve never met.

“Funnily enough, the most important thing you can do is announce yourself at the start,” says Rogers.

“There’s a lot of noise, you wouldn’t believe how loud it gets, all these people are talking over each other. I have to come in and make it clear that I’m running the trauma. My job is to orchestrate: delegate roles, update everyone on new developments and where we’re at, and keep side communication to a minimum.”

 

Share information early and often

In training, doctors learn early on that the best way to figure out the unknown is to start by stating your known facts. The first things to check for are the ABC’s: airway, breathing, and circulation. If Rogers isn’t positioned at the head of the bed, he’ll call out to whoever is there to find out the status of the patient’s ABCs. “That gets you into the first couple of minutes. Now everyone has some basic information to work with but, more importantly, I’ve bought myself some time to figure out what needs to happen next.”

As machines beep and carts clang, Rogers has to continue to rise above the din to keep everyone on the same page.

“It’s easy to get lost in where the team is at in the process. One nurse could be changing an IV here, another could be checking vitals. I have to constantly recap what’s happening. Even if we’re just a minute into it, I’ll say something like, ‘Okay, so just to recap where we’re at, this is a 30 year old man who got hit by a car. We have established that he’s breathing on his own. His leg is broken.’ There’s a million different dynamics and bits of information to process at the same time.”

This is what makes callbacks essential, something Rogers has been dinged for missing in past simulations: “Say I ask a nurse for the patient’s glucose level and she responds, ‘It was 72’, but it was too noisy to hear, if I don’t repeat, or call back, she’ll know I didn’t hear her.”

 

Get second opinions

Recapping events as they unfold, out loud, also helps to prevent one of the most fatal decision-making mistakes in the ER: Anchoring, a common cognitive bias that describes people’s tendency to rely too heavily on the first piece of information presented (the “anchor”) when making decisions, then basing all subsequent decisions on that information.

“There are times when you’ll be working off an initial diagnosis, then mid-way through you find out the patient had a stroke three days ago which can totally change your course of action,” says Rogers, “talking through the process out loud isn’t just about controlling the flow of information in the ER, it’s kind of an invitation to your teammates to provide their input, check your thinking, and make sure you’re not getting stuck on one idea.”

For all its challenges, it’s in these moments Rogers is grateful to have chosen the ER over other medical disciplines. “It’s not like up in surgery, where the attending is sort of the lord ruler and everyone’s just doing what they say. The ER is more democratic. Emergency is a team sport.”

 

Lima Al-Azzeh is grateful for the service of ER doctors.

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