Preparing the Team Chapter 2 PREPARING THE TEAM † ‡ SIMON MERCER, FRCA*; R. SCOTT FRAZER, MB, CHB, FRCA ; AND DARIN VIA, MD INTRODUCTION HUMAN FACTORS IN DEFENSE ANESTHESIA Communication Use of Standard Operating Procedures Situational Awareness Leadership/Followership Familiarization With the Environment and Equipment THE MULTIDISCIPLINARY TRAUMA TEAM TRAINING THE TRAUMA TEAM LIKELY ANESTHESIA TASKS AND CONSIDERATIONS Scenario 1. Bilateral Above-Knee Amputations Scenario 2. Possible Hypovolemic Shock Scenario 3. Damage Control Surgery With Multiple Injuries Scenario 4. Fluid Replacement With Multiple Injuries SUMMARY *Surgeon Commander, Royal Navy; Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, United Kingdom †Colonel, Late Royal Army Medical Corps; Consultant in Anaesthesia, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham B15 2WB, United Kingdom ‡Captain, Medical Corps, US Navy; Naval Medical Center Portsmouth, 250 Makal PA Drive, Pearl Harbor, Hawaii 96860 31 Combat Anesthesia: The First 24 Hours INTRODUCTION As an introduction to this chapter on preparing the injury patterns seen with military trauma (mainly team and environment for a deployment as a military blast and ballistic injury) are very different than the anesthesiologist, it is important to point out that there blunt trauma that predominates in UK and US civil- are several differences between United Kingdom De- ian trauma practice.3–-5 Deployed anesthesiologists fence Medical Services (UK-DMS) anesthetists and US are required to work with equipment they are not military anesthesiologists. familiar with and therefore must train to become UK-DMS anesthetists predominantly work in the competent with the equipment prior to deploying. National Health Service (NHS) and deploy on opera- Additionally, the military has unique guidelines or tions once every 6 to 18 months depending on their standard operating procedures (SOPs). In the UK role. Both regular and reserve personnel contribute to these are written as Clinical Guidelines for Opera- a consultant cadre of about 180. A number of trainee tions,6 and the US Army Institute for Surgical Re- anesthetists also deploy and complete a higher military search publishes the Joint Theater Trauma System training module in accordance with the Royal Col- Clinical Practice Guidelines.7 In military trauma, lege of Anaesthetists program.1 Hospital units tend the traditional resuscitation guidelines of airway, to change at 3 or 6 monthly intervals, and individuals breathing, and circulation (ABC) are modified to are often “trickle posted” as individual replacements <C>ABC,8 where <C> indicates the control of cata- deploying for 8 to 12 weeks. strophic hemorrhage. Other differences include the US military anesthesiologists include both active early and rapid use of blood and blood products as duty and reserve component personnel. Active duty part of damage control resuscitation.9,10 anesthesiologists are full time uniformed officers Predeployment training allows individuals the op- working within the military health system at military portunity to become fully immersed in the operational medical treatment facilities around the world at both environment and familiar with the new equipment. operational and fixed facilities. The average deploy- The busy operating room schedule in the deployed ment cycle is every 5 years across the services. This environment necessitates that individuals are comfort- infrequent deployment cycle is mostly due to the rapid able with the unfamiliar equipment and environment.11 turnover of personnel retiring to civilian practice after For instance, in a conflict environment an alarm bell their initial service obligation has been completed. might be a signal to drop down flat on the floor (“on Reserve personnel have a similar deployment cycle; your belt buckle”) because of an incoming mortar however, when not on duty they work within the ci- attack, whereas in a civilian setting it might signify a vilian healthcare sector. The average turnover for US fire alarm or a patient’s cardiac arrest. First-rate hu- forces is 6 months to 1 year, although specialists within man factors or nontechnical skills are important in the US Army and US Air Force may be reposted more this environment, and effective clinicians use them frequently. Despite these differences, the two groups as part of their working routine.12 The clinical tempo share similarities of practice, which will be discussed in theater precludes the potential for any significant in terms of predeployment training. “just-in-time” training. The whole medical system Military hospitals in Iraq and Afghanistan man- must be prepared to work in the deployed environ- aged considerably more severe trauma than an ment and rapidly integrate individuals into the team average UK or US hospital.2 As a consequence, the when they arrive. HUMAN FACTORS IN DEFENSE ANESTHESIA In the 1970s simulation in healthcare began gain- To Err Is Human, which showed that between 44,000 ing recognition as a means to limit human error and and 98,000 people die in the United States every year improve patient safety. The advantages of simulation from medical errors.15 Multiple case reports and a re- training had been clearly demonstrated in the aviation port from the UK National Patient Safety Agency also and nuclear power industries as well as the National suggest that human factors contribute to the majority Aeronautics and Space Administration (NASA). Pre- of medical errors.16–19 viously, NASA had shown that 70% of its errors were Research on human behaviors has led to the de- due to human factors such as failed interpersonal velopment of a set of behavioral principles initially communication, decision-making, and leadership.13 termed Crew Resource Management (CRM). CRM, Similar figures have been seen in an analysis of adverse also called human factors, is defined as “the cognitive, events in anesthesia14 and also in the landmark report social, and personal resource skills that complement 32 Preparing the Team technical skills, and contribute to safe and efficient Communication task performance.”20 As adapted for anesthesia, these principles are listed in Exhibit 2-1. It is essential that the flow of information from the Carthey et al21 reported that highly performing point of wounding to the trauma team in the field surgeons demonstrated nontechnical skills as an hospital is accurate. The initial military communica- integral part of their surgical expertise, and these at- tion tool is the “9 liner”24 evacuation request, which tributes were thought to play an equally significant medics on the ground use to request the evacuation role as technical skills. Ineffective communication was of a casualty. Once the casualty has arrived at the Role found to be a causal factor in 43% of errors by surgeons 3 field hospital, a standardized report is given by the in three US teaching hospitals.12 Human factors are evacuation team detailing the trauma incident. Unless also very important in the critical care environment, an obvious problem must be immediately addressed where patients have life-threatening illness, diagnostic (eg, airway compromise), it is important that all receiv- uncertainties, and the potential for rapidly changing ing team members remain silent and listen during this medical conditions, and are managed along variable exchange to maintain their own personal situational treatment pathways. Patient care is carried out over awareness. a 24-hour period involving multiple team transitions Other essential lines of communication for the and moves to different areas of the hospital, which trauma team include the following: can result in lapses and discontinuities in communi- cation.22 In the UK, the Houses of Parliament Health • The trauma surgeon needs to liaison with the Committee has recently acknowledged that a paucity team leader about the timing of procedures of nontechnical skills can have lethal consequences for and movement to the operating room or com- patients and that the NHS as a whole lags unaccept- puted tomography (CT) scanner. ably behind other safety-critical industries, such as • Radiology personnel are often present in the aviation, in this respect.23 The following are key hu- emergency department to provide immedi- man factors that are essential to the effective working ate digital x-rays or ultrasound scans. They of the trauma team. also require communication for CT scans if appropriate. • Staff providing transfusions need to be up- dated on resuscitation requirements if addi- tional “shock packs” or other blood products are required. EXHIBIT 2-1 • Operating room staff must understand the CREW RESOURCE MANAGEMENT KEY patient’s injuries to prepare the operating PRINCIPLES room to receive the casualty. • Critical care unit services are often required after surgery. • Know the environment. • Evacuation assets should receive early commu- • Anticipate and plan. nication in preparation for transfer to Role 4. • Call for help early. • Exercise leadership and followership. • Distribute the workload. Use of Standard Operating Procedures • Mobilize all available resources. • Communicate effectively. SOPs are developed from available evidence and • Use all available information. expert opinion and provide guidance to ensure a • Prevent and manage fixation errors. consistent approach to patient management, which • Cross (double) check. may improve the quality of care.25 SOPs have been • Use cognitive aids. commonplace in the