It’s 2am. This is your 3rd shift in a row. You haven’t had a break. You’re hungry. You’re tired. Your bladder is full. You’ve just transferred yet another patient out of your trauma bay, as it’s been a wildly busy shift thus far. Your brain is saturated!
You find yourself juggling numerous thoughts in your head involving both your professional and personal life. “Mr. Smith in bed 12 needs a repeat troponin; I need to remember to order that morning ultrasound on Mrs. Anderson; Mr. Jackson requires his antibiotics; Oh, that’s right…my daughter has her dentist appointment in the afternoon.” On top of the busy trauma room you are aware of the waiting room full of patients waiting to be seen. You are in a department with single physician coverage and nursing staffing for the shift has been less than ideal. You sit down and take a breath.
Then you hear it. The EMS phone goes off. You stop and listen as the paramedic on the other end begins to speak. “En-route to your hospital, code 1, with a 37-year-old male patient who was involved in a single vehicle MVC. He was ejected from the vehicle, has obvious head trauma and some large abrasions to the right side of his body. GCS is 9. HR is 105 bpm. BP initially was 75/45 mmHg but has now come up to 100/70 mmHg. We’re 5 min out.”
You feel the energy change instantly within your department. But before a mad scramble ensues you realize that 5 min is a long time in the world of emergency medicine. And instead of chaos, there’s clarity as you and your team assemble and prepare for this incoming trauma patient. And what better way to prepare then with the Zero Point Survey (ZPS).1
Everyone involved in resuscitation knows their alphabet. But before beginning the ABCs of the primary survey we can use a tool to be even more ready, more prepared and more equipped to STEP UP (Self, Team, Environment, Patient, Update, Priorities) our approach to a complex resuscitation. The ZPS is that very tool (see fig. 1). It starts as a pre-primary survey that can be conducted by many different teams in multiple environments (prehospital setting, ED, OR, ICU) that can enable you to prepare yourself, your team and your environment.
Figure 1. The Zero Point Survey
Prepare Yourself
Prior to our trauma patient’s arrival, we have 5 min to complete our ZPS. We begin with our own self. Are we, as individual health care providers, ready on both a cognitive and physical individual basis? The I’M SAFE (illness, medication/drugs, stress, alcohol, fatigue, eating/elimination) acronym provides us with a physical readiness checklist.2 No one should be “hangry” prior to a resuscitation so be sure to grab a snack. A granola bar or a piece of fruit could go a long way! Moreover, emptying your bladder can alleviate that nagging and unnecessary discomfort distracting your brain. So, take a minute to go pee and take a bite of that granola bar (with hopeful handwashing between those two). Your patient is now 4 minutes away.
Cognitive readiness, especially at 2 am, can be a challenge. However, it can be fueled by the ability to “Beat the Stress Fool”: Breath, Talk, See, Focus.3
Figure 2. “Beat the Stress Fool” mnemonic
- Breath
- Breathing is the only vital sign that we can consciously control. Controlled breathing4,5 can be used in this type of high stress situation to minimize hyper-arousal. It can be used maintain a sense of calm prior to a potentially stressful situation.
Figure 3. An example of triangular or tactical breathing from giphy.com
- Talk
- Positive self-talk is key when it comes to reframing what our mind perceives as a threat and how we can turn that into a challenge. Remind yourself of your previous training and abilities to resuscitate successfully. Maybe talk out a thought or a procedure with a team member. Grab one of your checklists and go over it to reinforce your knowledge.
- See
- Much like NBA players visualize themselves making free throws prior to even touching a basketball or how an Olympic Alpine skier will see themselves skiing a race in their mind prior to putting on skis, so too can we as healthcare providers undergo mental rehearsal to prepare for our incoming trauma patient. Active visualization of a technique, procedure or system can help to establish the mental mindset required for the desired outcome.
- Focus
- “We got this.” “Slick.” “Alright.” All examples of using a trigger word, or phrase, to focus your attention on the task at hand.
Your patient is now 3 minutes out.
Prepare your Team
Once we’ve prepared ourselves, we must now prepare our team. This includes identification of a team leader, role allocation and a team briefing.
Identifying a team leader is crucial to running any resuscitation. There needs to be that one individual, or pair of individuals responsible for the oversight of any resuscitation. Otherwise, we could be left in a situation where we have 5 providers all giving orders or asking for medications and equipment. This can leave the team confused, frustrated and disorganized. Keep in mind, the team leader can be a fluid model. The current leader may need to hand that role to another as they are about to become more task-oriented than team-oriented. This, in turn, can be handed back once the task is accomplished.
A good team leader establishes his/her team member’s roles in a collaborative fashion. Not only is it of the utmost importance for team members to know their particular role within the team, they must also be comfortable in said role. Asking a team member to establish IV access during a high stakes situation when they have never done so makes no sense. Ensure your team members are comfortable in their roles. Remember, if they’re comfortable, they’re confident! And if they’re confident, they’ll communicate!
Our patient is now roughly 2 ½ minutes from coming through the doors of our trauma room. We’ve prepared ourselves. We’ve established a leader and roles have been delegated. Now, we must pre-brief our team. To do so, our team must answer 3 questions. What do we know? What can we expect? How can we prepare?
What do we know?
From our EMS colleagues, we know this is a 37-year-old male ejected from his vehicle at highway speed. His GCS is 9. He had a transient drop in his blood pressure in the field and currently has a shock index of greater than 1.
What can we expect?
The answer to this comes from what we know. The low GCS makes us consider the possibility of traumatic brain injury (TBI) and the inevitability of advanced airway management. The drop in BP, the high shock index and the mechanism of injury all point towards hemorrhagic shock, potentially from a pelvic fracture, intra-abdominal bleeding and/or significant chest trauma.
How do we prepare?
Again, we can continue along from what we know and what we expect. Having an airway team with advanced airway equipment at the bedside and preparing for a potentially difficult airway would be essential. Also, having your scalpel-bougie-tube for front of neck access (FONA) easily accessible would be wise. Setting up bilateral chest tubes kits at either side of the bed or having scalpels at the ready for emergent decompression via a finger thoracostomy technique would reduce time to a potentially life-saving procedure. Lay out a pelvic binder or a blanket on the bed prior to the patient’s arrival. Have your ultrasound machine at the bedside, warm your level 1 infuser and call for blood early. Moreover, consider notifying your blood bank of a possible mass transfusion protocol (MTP). Have your team members in their designated positions that revolve around their roles and prepare for a clear and concise handover from our prehospital colleagues.
Team leadership, clear role allocation and concise pre-briefing allows for a shared mental model for the team and the tasks potentially at hand.
Our patient is now one minute away.
Prepare your environment
This is your team’s final opportunity prior to patient arrival to take a quick scan of your surroundings. Do you have enough space for your resuscitation? If not, do some things need to be removed from your trauma bay? If you haven’t put on your personal protective equipment (PPE) now is a good time to do so. Make sure there are no floor hazards that you could trip on. And ensure you control your resuscitative environment – it is ok to maintain crowd control by asking non-team members to step back and/or leave until potentially called upon. These are just a few examples of how to ensure both your team’s and your patient’s safety.
Your patient now arrives in your trauma bay. And, rather than scrambling to decide who is doing what, wondering where essential equipment is and having yourself in a poor headspace, you find yourself prepared physically, mentally and emotionally at the task at hand. Your team can immerse themselves into the primary survey of the patient. A right sided pneumothorax is decompressed, the pelvis is bound and MTP is initiated. You continue to give frequent updates to team members during the resuscitation to ensure a shared mental model within the team and verbalizing the next priorities in patient care. “Our patient’s vitals have improved with the treatment we’ve initiated. Our next step will be to secure this patient’s airway. Let’s grab our airway checklist.”
And with that, our team has used a STEP-UP approach to successfully resuscitate our patient. The ZPS provides us with the critical steps we can follow to be more prepared to function as a cohesive resuscitation “pit crew.” It is something we can all implement (at zero cost) into our practice tomorrow and is one of the many strategies that will allow us to continue working better, together!
By: Angus MacDonald, MD
References:
- Reid, C et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med 2018;5(3):139-143.
- Wikipedia. IMSAFE [Internet]. San Francisco, CA: Wikimedia Foundation; 2016. Available from https://en.wikipedia.org/wiki/IMSAFE.
- Lauria, M.J et al. Psychological skills to improve emergency care providers’ performance under stress. Ann Emerg Med. 2017 Dec;70(6):884-890.
- Mesagno, C & Mullane-Grant T.A. A comparison of different pre-performance routines as possible choking interventions. J App Sport Psychol 2010;22:343-60.
- Anton, NE et al. What stress coping strategies are surgeons relying upon during surgery? Am J Surg 2015;210:846-51.
Be sure to check out our other posts such as our discussion on the disutility of exercise stress tests in patients with low risk chest pain.
