Grand Rounds Summary 01.04.17

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Promise and Pitfalls of Teams in Emergency Medicine with Andrew Knight, PhD

The number of teams working and creating innovations in all fields (except for Arts & Humanities) is increasing, as is the size of said teams. 

A team of people with diverse perspectives and expertise can tackle highly complex problems more effectively and efficiently than people working alone. 

Realizing the Promise of Teams

  1. Team members must truly have the expertise they are supposed to have
  2. Team members must understand who has what expertise
  3. Team members must a) share their expertise and perspectives and b) defer to those with relevant expertise

The Reality of Teams in (Academic) Emergency Medicine

Unique Challenges: Workload is unpredictable; tasks are of uncertain complexity and acuity; team composition likely changes shift-to-shift; workforce may change month-to-month. Implication: Team members are constantly forming judgments of people they barely know, to coordinate on the fly

How do team members form judgments about one another?

Core Dimensions of Interpersonal Perception

  • Competence: Judgments about ability or capacity to perform; relatively cognitive, domain-specific
    • Dominant Signal: Positive behavior
    • Malleability: Mostly fixable
  • Character: Judgments about orientation toward the group; relatively effective, diffuse
    • Dominant Signal: Negative behavior
    • Malleability: Mostly fixed

Competence is seen as malleability, Character is seen as fixed

These judgments are made quickly and are self-reinforcing.

Expectations shape reality: When leaders expect someone to perform highly, the person performs highly

Implications:

  • For you and your reputation on your team
    • Build your reputation for competence
    • Protect your reputation for character
  • For you in perceiving others on your team
    • Take time to be curious about others
    • Be open to being wrong about your first impression

Hierarchy and climbing team outcomes: Teams from countries with more hierarchical cultures summited more, but had more climbers die along the way, why would this be?

Hierarchy Condition: More coordination, less psychological safety and information sharing

Decentralized Condition: Less coordination, more psychological safety and information sharing

The Hierarchy Helps View: useful where there is a lot of turn over, where things are taught by watching

The Hierarchy Hinders View: lack of upward flow of information

High Power Condition: Asking people to recall in a particular incident in which you have power over another individual or individuals

  • Activates the approach system
  • Focuses on action
  • Motivates pursuing opportunities

Low Power Condition: Asking people to recall in a particular incident in which another individual or individuals had power over them

  • Activates the react system
  • Focuses on reaction
  • Motivates minimizing risk

Hierarchy offers many coordination benefits

  • Facilitates plug and play teaming
  • Structures groups of experts and novices

Practices to Help Realize The Promise of Teams in Emergency Medicine

  • Routinize a comprehensive team training program
  • Encourage deference to expertise, not just role
  • Flattening the hierarchy when it is less functional
    • Debriefings, M&M conferences
    • Teaching moments on shift
    • Example: Low status speak first in debriefings
  • Consciously overcome default tendencies
    • High power folks must consciously invite voice
    • Low power folks must consciously provide voice
  • Subtly personalize the teamwork

http://apknight.org/healthcare-teams.zip

MARCH Against Trauma with Ryan Knight, MD

Where MARCH came from? Hemorrhage is killing 4/5 people who should be alive coming back from overseas. Implementing MARCH was an attempt to intervene on fixable life threats quickly and efficiently. 

MARCH:

  • Massive Hemorrhage: stop the outflow
    • Ground: 
      • Claw method to find bleeding
      • Tourniquets high/tight
      • Stop the bleeding then apply a new one above the wound
      • Pressure dressing: get on the bleeder; don't just guess
    • Chest:
      • Surgical!
      • Finger or tube thoracostomy
        • To clamp or not to clamp? That is the question
    • Abdomen
      • Surgical!
    • Pelvis
      • Close the space
      • REBOA?
    • Thigh
      • Pull out displaced fractures
  • Airway: tongue is the most common obstruction of an airway in trauma
    • Try to avoid buying the airway if you can help it
    • Roll onto their side, put a hand under the chin
    • Allowing patients to sit up or position themselves where they can breath
    • Use nasal or oral airways when able
  • Respirations: tension PTX happens more often than thought
    • Mechanism of injury + 1 sign of tension PTX= needle decompression
      • SOB
      • Pain
      • Difficulty Breathing
    • 4th-5th Intercostal space, mid axillary line
    • Leave catheter in place
  • Circulatory: (picture the triad of death)
    • Consider TXA: give it over 10min due to hypotension when given faster
    • Use the hypotensive resuscitation guidelines
    • What fluids are best?
      • Controversial whether blood products or crystalloid should be used as a resuscitation fluid. 
      • Plasma first?
    • Warm fluids if possible
  • Hypothermia: 
    • Get them off the ground
  • Head Injury:
    • 83% of nonsurvivable deaths were head injuries 
    • Avoid hypoxia, hypotension, maintain normothermia (do MARCH correctly to prevent many of these)
    • Antibiotics
    • Seizure prevention
    • Head of bed
    • Loosen anything restrictive
    • C-collar-- NOPE
    • Hypotensive resuscitation

REBOA with Ryan Knight, MD

History of REBOA: initially described by a surgeon during the Korean war, tried again by surgeons in the 80s

Steps for REBOA placement

  1. Arterial access
    • Common Femoral Artery arterial line for any sick trauma
    • US guidance then cut down
    • Must be CFA 
  2. Balloon measurement
    • Zone 1- End of the sheath to <= 2cm above xyphoid
    • Zone 3- End of sheath to <= 2cm of umbilicus
  3. Balloon positioning 
    • Tread through sheath to your predetermined measurement
    • Do not push through resistance
    • Twist/Pull back
    • Do not try to advance partially inflated balloon
  4. Balloon inflation
    • Inflate balloon until gentle resistance (5-25cc for ER-REBOA)
    • Distal pulses should cease
  5. Balloon deflation
  6. Sheath removal
    • Hematoma
    • Complicated arterial repair
    • Arterial dissection/thrombus

Patient Selection: Refractory hemorrhagic shock due to non-compressible truncal hemorrhage

  • Penetrating abdominal trauma
  • Blunt trauma
  • Bridge to definitive intervention

REBOA Algorithm: hypotensive with injuries to the trunk

Zone 1: Intraabdominal injuries needing an ex-lap 

Zone 3: pelvic injuries who need IR or surgical intervention

Concussion with William Knight, MD

Concussion: most common type of TBI

Suggested maximal force amplitude: brainstem, corpus callosum, fornices

Metabolic demand: pathologic ion shifts-->mitochondrial dysfunction-->ATP depleted

No standard definition of Concussion:

American Academy of Neurology: trauma induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are hallmarks

American Academy of Neurosurgery: clinical syndrome resulting from mechanical force or trauma: immediate and transient alteration in mental status

Baseline testing is important to know if they have subtle changes.

H&P: Diagnosis of concussion resides in the history. PE is often unremarkable.

  • Perform a thorough neurologic exam
    • BESS (Balance Error Scoring System)
    • Vestibular Ocular Motor Screening 
      • Saccades
      • Convergence
  • Assess cognitive function (baseline intelligence)
  • Neuropsychologic testing ($$$)
    • Mild to moderate impairment within the first 24h
      • global functioning
      • memory acquisition
      • delayed memory
    • 85-90% have full neuropsychologic recovery within a week

Persistent Concussive Symptoms (10-20% of concussions)

  • History of TBI
  • Presence of >3 symptoms 

Long term outcomes: cumulative effects of concussions on long-term neuropsychological function. Studies showing no differences v studies showing significant differences

Repetitive (sub)concussive effects: May not be evident until 30 years after

Chronic Traumatic Encephalopathy: A progressive neurodegenerative syndrome cause by episodic and repetitive blunt force impact to the head and transfer of acceleration-deceleration forces to the brain. 

Treatment of concussion: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport

  • Physical and cognitive (brain) rest until resolution of acute symptoms followed by a gradual return to normal activities
    • Challenged recently due to lack of scientific evidence
    • Now limited to 24-48h of brain rest
    • Progress back slowly