As a new paramedic, I’ve spent a lot of time thinking about my new role as a leader and manager. As myriad recent studies have shown, effective leadership during CPR events leads to better outcomes. That’s to be expected.
My question is, can we create evidence-based resuscitation management guidelines that can be considered in all resuscitation events.
Using the Incident Command System as a point of inspiration, is there a process that prehospital providers can use to manage every call they take, from a nursing home fall to a traumatic code. The goal is to have a mental checklist of sorts that is a formalization of the thought process that occurs fluently in experienced medical providers in order to create a structure that considers the steps for effective team-building.
With this as my springboard and using evidence-based medicine as my backboard, this is what I’ve come up with:
1) Pre-Plan— With very few exceptions, prehospital providers have some period of time in which they can preplan their approach to a call based on dispatch information. This window of opportunity, even if only brief, is crucial for the provider moderating their own thought process and for communicating with their partner(s) about the way in which they want to handle the call.
One simulator-based study of physicians in CPR scenarios found that clinical outcomes are negatively affected by shortcomings in the process of ad-hoc team-building and deficits in leadership. Establishing some sort of team unit, initiating a structure, and mentally preparing for the scenario ahead may be the largest luxury (regarding resuscitation management) afforded to pre-hospital providers responding to emergencies.
2) Establish Yourself as the Leader— This point encompasses a couple of points. First of all, the lack of a defined leader leads to poorer outcomes when there is any question of hierarchy during a resuscitation. As noted in the above study, establishing a structure eases information flow, which is obviously crucial in resuscitation situations.
Having a clear leader on a scene also allows for structure to develop more fluently. On any fire scene, everyone knows to look for the white helmet talking on the radio (he might even be wearing an “Incident Commander” vest if the scene is large enough). On an EMS call, the paramedic patch on your arm might clue others in to the fact you’re in charge, but it’s never that simple. Having a calm, confident presence and presenting yourself as the head-cheese-in-charge facilitates a more fluid resuscitation.
3) Assign Roles– The driving force behind these guidelines is, if you couldn’t guess, structure. Structure primarily provides some semblance of comfort in chaos but also allows each member of the team to be effective. When the leader of a resuscitation assigns roles or tasks, it leaves no doubt as to what each team-member should be doing, and (perhaps most importantly) it helps the leader focus on leading.
One of the most cited studies in the resuscitation management literature (that I’ve come across) is from a the European Resuscitation Council, which found that the absence of leadership behavior and explicit task distribution were associated with poor team performance (emphasis my own).
Another most-important piece of literature is the “Lighthouse Leadership” study, also from Resuscitation. This paper found not only that building a structure in the resuscitation is essential to performing effectively but also that leaders were more effective when “hands-off.” Those who do so can prioritize treatments, plan the resuscitation, and are more inclined to make changes when needed. I won’t dwell on it much longer, but this may very well be the most important step in a well-lead resuscitation.
4) Verbalize and Continue Communication— Again, it may sound like common sense and/or something that is already regularly done, but explicitly verbalizing treatment plans, exam findings, and changes in patient condition invariably leads to better outcomes. A formally verbalized treatment plan/plan of attack prior to arrival on scene may be the closest thing pre-hospital providers have to the checklists and time-outs that have made such drastic improvements in the OR setting. (I don’t have a citation for this one; just start reading everything Atul Gawande ever wrote).
As for continued communication, we all know about the closed-loop communication of the ACLS class room–and I think that certainly is important–but members of the team should not just be a confirmatory echo. An interesting (but rather limited) simulator study found that unsolicited team-member contributions may prevent critical errors from occurring. One example of this that comes to mind is the Resuscitation Academy’s suggestion that “EMTs Own CPR.” This means that even the lowliest, greenest, most wet-behind-the-ears EMT-B should be able to point out that nobody is doing compressions, or that compressions are being performed poorly. Obviously there are many issues inherent in individuals other than the leader speaking up in those situations, but the idea is to foster the environment where everyone is comfortable contributing to a successful patient outcome.
I would just like to emphasize again that these are my own musings as I work on becoming a more effective leader, and I welcome any comments/suggestions/ideas that you might have related to creating a framework that could be used for managing any given patient encounter. Such guidelines could be used for training and teaching, which is a whole other (but important) topic of conversation.