You put on your N-95 and face shield and race to the OR. The bloodied, injured patient is wheeled in by first responders who yell out their understanding of what has transpired leading up to the point of arrival.
What do you do?
According to Centers for Disease Control and Prevention data from 2000 to 2019, the leading cause of death in the United States from ages 1 through 44 was unintentional injury (asamonitor.pub/3FJ8DH8). At Memorial Hermann-Texas Medical Center, the busiest level I trauma center in the U.S., the anesthesiology department is no stranger to caring for trauma patients at a moment’s notice, the second they arrive. While there are innumerable considerations during the pandemonium that is a fresh level 1 trauma, perhaps the most paramount factor that helps improve patient survival is communication.
“While traumas can be chaotic, anesthesiology teams can run like well oiled machines with thoughtful delegation and clear communication.”
When approaching a trauma, preparation and efficient utilization of resources are vital. This requires knowing which personnel are available and how to reach your team so they may assist with resuscitation efforts. At times, you may have a full team of faculty anesthesiologists, resident physicians, students, technicians, and nurses, and at other times, your team may be spread thin among multiple ORs at dusk. Knowing the strengths of your team members and succinctly delegating tasks are keys to optimizing efficiency, as it ensures that every aspect of trauma care is given the diligence it necessitates. If multiple anesthesiology team members are available, each member should be assigned a specific task to focus on, such as the airway, intravenous access, or arterial line access. While traumas can be chaotic, anesthesiology teams can run like well-oiled machines with thoughtful delegation and clear communication.
Anesthesiology team members are tasked with preparing medications, airway equipment, and coordinating with ancillary staff to ensure that every tool necessary to facilitate trauma care can become available. One of the cardinal goals is knowing how to ask ancillary staff, such as co-residents, pharmacists, nurses, and anesthesia technicians, for medications, equipment, and transfusion products essential to treating trauma patients; this involves knowing what resources are at your disposal. At the beginning of every shift at our institution, it is routine to stock every designated trauma room with ultrasound machines and arterial line and central line supplies, video laryngoscopes, crash carts, and rapid fluid infusers. We also communicate with our anesthesia technicians closely to bring additional special equipment such as bronchoscopes, transesophageal probes, and double lumen tubes when they may be needed. We then communicate with circulating OR nurses immediately to ensure we have transfusion products as early as possible.
Next, we make a plan for when the patient enters the OR. The moment the patient arrives to the OR, all attention is shifted to the patient and the first responders. The mechanism of injury, resuscitation received en route, concerns for airway compromise, and established venous accesses are crucial details that must be communicated; it can change how each facet of keeping a patient alive for surgery is triaged appropriately. The attention should then be shifted to moving the patient to the OR table and discussing with the surgeons what operation will likely be performed and which patient positioning and hemodynamics will help optimize surgical conditions. It is also pivotal to articulate our initial concerns as well as the vitals signs, initial lab results, and ongoing resuscitation strategies. Once the case begins, constant, unabashed communication with the surgical and nursing teams is essential, including but not limited to the amount of resuscitants given, vasopressor requirements, and signs of further clinical deterioration and improvement. Furthermore, it is imperative to be mindful of what is occurring in the operative field. Have the surgeons achieved source control? Are there blood vessels clamped? Is there visualized coagulopathy? Is there a higher-than-anticipated amount of blood loss? Are there further procedures that may be necessary? Are there other pathologies at play? These are just a few of the many questions that guide our therapy as anesthesiologists so we may anticipate what the patient may need to ensure a meaningful survival.
In major trauma settings, there are many moving parts, sometimes under suboptimal and challenging circumstances. Successful resuscitation is typically centered around effective communication because it ensures that every individual is on the same page and facilitates an efficient, quality, and organized method of helping each trauma patient’s chance of survival. As the sentinels of our patients, particularly in trauma care, we are called upon to be vocal leaders in the ORs because our management strategies and resource utilization can determine our patient’s outcome.