Resuscitation Team Dynamics
Picture the following scenario: an elderly gentleman has been working out in the field when he is stung by a bee. He is allergic and immediately gives himself a shot of adrenalin from his Epi-pen. There is no one else with him and he is miles from town, so he gets in his truck and drives to the hospital. By the time he arrives, the adrenalin has worn off- unfortunately, it wasn’t enough to stop the deadly reaction precipitated by the bee sting. He is diaphoretic, having difficulty breathing and his blood pressure is dangerously low. Even more worrying, he is complaining of substernal chest pain.
The staff immediately swing into action. Everyone begins to work frantically. One nurse is attempting to gain IV access. Another is struggling to get his clothes off. An LPN is trying to obtain a blood pressure reading. A lab tech is present and is standing back, awaiting orders. Everyone is talking over everyone else. The doctor is yelling loudly above the noise for someone to give epinephrine before the patient arrests. It is mass chaos.
Of course, it is always preferable to have ample warning when an emergency comes in, time to check equipment, set up IV lines and time for the physician or team leader to assign roles so that everyone has a clear idea of what their particular job will be. Unfortunately, emergencies aren’t always so neat; instead, they are too often messy and unorganized, like the scenario described above. Some teams work efficiently and effortlessly together, while others founder like a ship without a rudder. Successful resuscitation requires a leader. It also requires a team that functions as a team, with everyone performing their role seamlessly. Clear communication and mutual respect are an important part of both managing and being a team member during a resuscitation attempt.
It may seem trite, but communication is possibly the most important element in a successful resuscitation. The potential for disaster should someone’s orders be misconstrued is evident. However, effective communication is learned, at least for most of us- we aren’t born knowing how to communicate effectively. In order for communication to be effective, it must be open and must occur frequently during resuscitation. Important elements of communication include:
- Respect - communication is based on respect, and this is never truer than in health care. Professionals, no matter their level of expertise, should be permitted, even encouraged, to question others and voice their opinions. When individuals feel free to voice their thoughts and opinions, errors are avoided. Staff who are too intimidated by a bullying physician will never question his/her orders, even when they are wrong. In a resuscitation situation, it is of utmost importance that everyone present feel that they are able, and welcome, to voice opinions and ask questions. Respect in the cornerstone of good communication.
- Constructive criticism - criticism need not be a bad 9-letter word. When verbalized correctly, constructive criticism helps us to learn and grow as professionals. In the wrong hands, however, constructive criticism is only criticism. As professionals it is important to learn how to give (and take) criticism the way it is intended- as a tool to enhance learning. We’ve all been criticized by someone who didn’t understand the difference between criticism and constructive criticism. “Only an idiot would think that this patient is in heart failure” is a world apart from “That’s one idea, but the patient’s lungs are clear and there is no edema. It was a good thought. Do you have any other ideas? Anyone?” Obviously, in the second scenario, the person who ventured forth an idea is not belittled and might actually learn something, as well as being encouraged to try again. A good leader learns how to value the members of their team and knows how to extract the best from them, in both knowledge and effort.
- Constructive intervention - this is the other side of the constructive criticism coin. Team leaders and team members must both be able to intervene when a mistake is about to be made, or when a crucial step is forgotten. This is easy for team leaders, but is far from easy for team members who may be subordinate to the team leader. It is sometimes easier to remain quiet rather than to “rock the boat” and point out a potential error or missed step. Good leaders will encourage a culture in which all members of the team feel comfortable speaking up, no matter who they might be afraid of offending. It should always be acceptable to question a person with more training and experience when the end goal is patient safety.
- Repeating the obvious - repeating orders is common, but it is never more important than in a code situation. This is known as closed loop communication; that is, the person receiving the message repeats the message heard, which closes the loop of communication with the person giving the message. This allows the message sender to ensure that the message was received correctly and the message receiver to ensure that what they heard was indeed the correct message intended. Doing this increases the chance that any errors made will be caught, and also ensures that other team members are aware of what to expect next. Although it may seem obvious, and even unnecessary to some, repeating orders is important and is a step that should never be missed.
- Using the algorithms - ACLS algorithms are intended to take the pressure off, so to speak. They provide us with clear guidelines and best practice when we encounter specific situations. There is no shame in consulting the algorithms- in fact, you are encouraged to do so. Algorithms provide us with a common language, no matter what our professional background may be. Algorithms also provide us with an easy out should an uncomfortable situation arise: “Excuse me, the algorithm calls for 1 mg of epinephrine followed by 2 minutes of CPR. Am I correct in my understanding?” This allows you to question anything without appearing as though you are directly challenging a specific person or their decision. Of course, such subterfuge should not be necessary if the team leader is clearly accepting of others’ opinions and ideas, but it never hurts to have another tool in the arsenal. Above all, algorithms keep us all on the same page.
- If you are the leader, act like one - if you are the team leader, everyone will follow your lead. If you are calm, everyone else will remain calm. If you encourage the respectful exchange of ideas, others will feel free to speak up and voice opinions. If you are assertive (without being obnoxious), others will gladly follow your lead. Act like a true leader and the resuscitation attempt is sure to go smoothly. Act like Napoleon and…you get the picture.
Communication is the most important interpersonal component needed in an emergency situation. For some, communication skills come naturally, while others must work at learning to communicate effectively and assertively. If you are in the second group, take the time to study effective leadership and management strategies before you are expected to assume this harrowing, but ultimately satisfying, role.
Fitzgerald Chase, A. Team Communication in Emergencies: Simple Strategies for Staff Zoll.com http://www.zoll.com/codecommunicationsnewsletter/ccnl04_10/ZollTeamCommunications04_10.pdf