St Emlyns - Meducation in Virchester #FOAM
A few weeks ago I was reading the most excellent Resus Room Management blog. It’s seriously awesome and you should check it out. [I've decided that all this social media engagement has made me sound decidedly non-English - and I've started to use words like 'awesome' - many apologies to the English ladies and chaps out there]
I came across a fascinating blog post on why “teamwork doesn’t work in Resus”. This was an excellent post on a number of levels, not least because of the mention of my beloved Manchester United, but it has also given me some real food for thought. You see, I’ve spent many years reflecting on ways to improve teamwork in Resus, and on how I can be a better leader in Resus situations. While I loved the blog post, I have to say that I disagree that there’s no such thing as a ‘team’ in Resus. I think that working well in the Resus Room is all about teamwork. So let me tell you where I’m coming from…
Notvery Athletic Football Club
Rick Body, Consultant in Emergency Medicine & Carlos Valderama Wannabe
One of my biggest interests outside Emergency Medicine is football [I'm the punk in the pic - although I only sport this particular hairdo for special occasions]. Outside of the Resus Room, I’ve captained Notvery Athletic Football Club in a Manchester 5-a-side league for almost 19 years now. Why am I telling you this? Well, believe it or not, Sunday league football has taught me a lot about leadership and teamwork that can be translated to the Resus Room.
How, you ask? Well, let’s examine the skills that are needed in Resus, then we’ll see what I’ve learned from the world of football.
Teamwork In The Resus Room
A ‘team’ is defined as a group of people linked in a common purpose. That’s exactly what we have in the Resus Room. Our goal is to resuscitate and care for the patient in front of us. We may not have had the opportunity to train together like Manchester United. With every ‘standby’, ‘trauma call’ or ‘red phone’ patient we receive, the group of heterogeneous individuals that assembles may well be entirely different. We may not have any choice about the skill mix available to us. We may not even know each other by name, but still our common goal can’t be doubted.
What can football teach us about teamwork in the Resus Room?
Not all football teams are like Manchester United. My team, the esteemed Notvery Athletic FC, started as a group of school friends and has evolved over the years into a group of loosely connected individuals, united only by one common goal – to play football the right way in accordance with the team’s values, and to beat the opposing Manchester Sunday league team without being killed. We have players who work shifts or who need to travel regularly with work. Our team line-up almost inevitably changes every week. Often we bring in friends of friends, occasionally cousins of cousins, at times anyone who can put on a pair of trainers and play! [If you fancy a game, give me your number!] Notvery Athletic FC is just as heterogeneous a group of individuals as a Resus team. We are, however, as much of a team as Manchester United will ever be and our team spirit is up there with the best of them.
How can a ‘group’ work as a ‘team’ under these conditions?
a. Leadership
First of all, every team needs a leader. For Notvery Athletic FC, that’s me. I’m not suggesting that I’m any good at it, but this is generally what I do each week. When the heterogeneous group of individuals that I call my team turns up to play football each Sunday, my first job as the captain/team leader is organisation. All players must be introduced to each other. Every player is given a chance to express their strengths, weaknesses and preferences for the game ahead. Once I understand the strengths, weaknesses and needs of my team I can then assign roles. Who will defend, who will attack? If we have one weaker player, certain others may need to know (discreetly) that they should pay extra attention to communication, and be aware that they may need to cover for the weaker player when things go wrong. A big consideration, when I’m assigning roles, is the opposition we’re facing. Perhaps they have a particularly good forward who likes to try a certain trick. Perhaps they have specific weaknesses that we can exploit. I don’t have a week of training sessions to point this out to my team – we have literally a few minutes to mentally prepare the team for what may lie ahead after the kick off. Lastly, I need to be clear that everyone understands the rules. This applies not only to the rules of the game but also the team’s code of conduct – e.g. who will be a substitute at each particular time.
In the Resus situation, the team leader is a vital role – but it is virtually identical to the role I play every Sunday in the football league. Next time you prepare to receive a ‘standby call’ give it a try. Introduce the team to each other if you need to, give them a chance to break the ice. Think about their individual strengths and weaknesses and explore their preferences for the Resus ahead. Think about the opposition you face. If this is a patient with GCS 3 who you may need to intubate immediately, who is looking after the airway? Are they a strength or a weakness for your team? If you spot a potential weakness, who’s going to cover for them in the event of trouble? Identify them, and let them know. Make sure everyone in the team knows their role, and mentally prepare the team by discussing what you perceive will be the biggest challenges in the imminent resuscitation. Be sure that your team knows the ‘rules’ of the game. In Resus, this may be simply pointing out the basic chains of command and communication, or pointing out that the team leader controls entry to the ‘red zone’ around the patient (often demarcated by a red line) in order that tasks are completed efficiently without crowding the patient.
b. Communication
A football team is highly unlikely to be successful if it’s members don’t communicate effectively. Of course, this is largely down to individuals. Some of us will be talkers and natural communicators, others will be quiet and not quite so strong in this situation. There’s not much you can do about this, but once again, you can be aware of your team and its strengths and weaknesses and adjust for them. In particular, you can create an atmosphere that fosters communication, that enables team members (including those of lesser ability, who may be less confident) to speak up and communicate with colleagues. Without effective communication on the football pitch, it takes a split second for the opposition striker to escape the attention of our defender and plant one in the back of the onion bag, as they say.
Resus is exactly the same. We need to be aware of who is strong at communication, who is a bit loud and who is a bit quiet. Sometimes the team leader might need to invite communication from the quieter members more than the rest. We need to promote an atmosphere that facilitates effective communication. And we need to play our part. Failure to communicate effectively in football can lead to conceding a goal. The same failure in the Resus Room could be far more costly.
c. The best laid plans of mice and men…
A wise man once said that “No battle plan survives contact with the enemy”. You can’t plan for all eventualities. In football, injuries, sending offs, unexpected scorelines and unanticipated tactics from the opposition all have to be dealt with. Once again, this calls for strong team leadership, effective communication and togetherness within the team.
A Resus team has to be able to deal with dynamic situations too. Failure to adapt and change tactics in football can lead to a heavy thumping from the opposition. In Resus, the consequences of sticking to your initial plans and holding to convictions are far more serious. All team members should feel empowered to raise valid concerns about the diagnosis and management plan. Nobody should feel too in awe of the team leader to express this. (In fact, many plane crashes have been caused by crew members who were too afraid of breaking rank and expressing concerns to the pilot). A good team leader should always listen to such concerns and consider whether the team needs to change tack.
d. Emotional intelligence
http://www.flickr.com/photos/robom8/4504165421/sizes/z/
Now here’s something that’s often underestimated. I’ll go as far as to suggest that the emotional intelligence of my football team contributes more to its success than the players’ ability. Football is a game filled with passion. In a Manchester Sunday league, sometimes this passion can go a little too far! After a couple of decades in the game, my regular players know that we have to channel our energy into the game itself rather than allowing ourselves to be drawn into confrontations with the opposition or arguments with the referee. Sometimes our opposition doesn’t have the same emotional intelligence. If you wish to, you can even manipulate this weakness by allowing the opposition to get wound up and make them underperform! Other teams have individuals who thrive with confrontation, in which case our players need to bring the emotions down a level by slowing the game down and avoiding situations that encourage confrontation.
Emotional intelligence is also massively important in the Resus Room. We can modulate the emotions if we recognise them. If the team is too high on adrenaline or too anxious, we can calm things down. A good team leader will do this. It can be difficult, at times. The last DSI I performed was in a peri-mortem patient who appeared to be breathing their last. My first job was to bring the team down an emotional level, which enabled us to control the situation and intubate in a safe, systematic and planned manner. If the patient dies of their condition, that’s very bad. If you kill them by reacting badly to their condition in an adrenaline-fuelled haze, that’s so-o-o bad that you really don’t wanna know.
Occasionally, you need to apply emotional intelligence the opposite way. I find that this often happens when managing patients with STEMI. The urgency of the situation isn’t always apparent to the team, who may amble through their tasks. In this situation, the team needs bringing up a level – but through motivation, not discipline!
e. Debrief
Every single Notvery Athletic FC football match finishes with a debrief. We reflect. We go through the key events. We talk about our favourite moments, what we did well. We laugh, we moan, we self-criticise. And, even if we’ve been crushed 10-0, we leave on a relative high note ready to come back and do it better next time.
In Resus, debriefing and reflection are really important for the team. Getting feedback from colleagues is crucial, especially for the junior and under-confident members of the team who need reassurance and encouragement. The debrief should really kick-start the reflection process for each individual. My Monday morning drive to work is often time for reflection about the Sunday night league game and how I can improve for next time. Similarly, each Resus team member is likely to go away and reflect (often extensively) on how the case went. The debrief is a chance to prime that process, to inform and improve it, and perhaps to enable the reflections to be more fulfilling than the sleepless nights I’m sure every emergency physician (including me) endures all too frequently.
Next time you’re part of a Resus team, try to think of Notvery Athletic FC and see if you can apply some of the principles of football teamwork in your Resus scenario. And please feed back about your thoughts and experiences! Until next time…
Rick
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