Do you struggle with differences in Trauma teams?

[MassED, BSN, RN]

I work at a level 1 trauma center in the ER. It's a teaching facility and we rotate trauma teams. Just like we can't choose the nurses that we work with in our trauma rooms, we obviously have no say in our teams and how they run their traumas. I'm acutely aware of the pain they create when there are multiple trauma docs, then our ED docs, who are all calling out orders. Do these trauma folks even run mock traumas? I'm just dealing with a bonehead chief resident, so I know it will end soon, just looking to vent.

Also, another issue that has me at wits end and is certainly NOT new in the ED, is dealing with nurses in the trauma room and some nurses not sticking to their role. Some can move effortlessly with other nurses, while some try to run things and try to order meds when the docs are standing right there calling out orders. In my mind, I think "what is going on?" Who do they think they are? We ALL know how to anticipate, but jumping on another's toes is not helpful and is wasting time. This situation I'm talking about is a nurse stating we need such and such med, not looking to see that I had meds in hand per the doctors order and another was held because it was given in the field. This nurse was too wrapped up in starting their IV to listen and was obnoxious about barking out what meds we need to give NOW.

When it's mass chaos, it's important to cool your jets and be clear about the orders with ONE main doctor. As nurses, our roles are specific and clear communication is essential at these times. You have your transcriber, your med nurse, and another for interventions. Sometimes we have a tech to help with VS, but often not.

I know not every nurse team works effortlessly together, but in times of trauma, it is essential that communication is key and for nurses to not take on the role of a doc. It's ludicrous and just need to throw that out there... I'm sure many of you all understand.

Have a great Saturday!!!

[VICEDRN, BSN, RN]

I hear you...there are some teams that I just cringe when I see them coming and then there are some times when I see who the ER docs are and who the trauma docs are and I see fighting coming.

My least favorite is when the patient is bad off and they stand there shouting out orders that are counter to one another and then blame the nursing staff for the lack of direction.

For example:

We need to go to CT NOW calls out the trauma surgeon followed immediately by "I need another line, let's get the foley in and...hey, do you think we need a central line? Let's hang some blood." It all comes out in one big thought.

Afterwards, they get mad if you start to pack the patient up for CT or get the tray to foley the patient or start working on a line. In trauma committee meeting, they then complain that the nursing staff didn't act quick enough but really its like, "Can y'all decide what the HECK you want for us to do?"

Believe it or not, I have actually said that out loud in a trauma before to get them moving but then they have to admit that they are at odds with one another or that they are saying contradictory things.

As for RNs that order, it depends on what it is. If it's labs, xrays and pan scan, I could care less. When its meds, I stay out of it but that's not how I practice.

[NO50FRANNY]

I avoid traumas during the day like the plague. If the bell goes off all these people appear from the back offices and it quickly becomes a too many chiefs, not enough indians scenario. At night, after hours, love it- nothing better than just a few people getting the job done well. I agree with VICEDRN- if it's a messy trauma it is always the nurses fault. I have also found a good rule of thumb, pick the primary physician and I do only what he or she asks. I too have had 6 different orders at once and very loudly and pointedly said, "right, in exactly what order do you guys want me to do w, x, y, and z, and which one of you is going to step away from the patient so that I can actually do it?" This was after being curtly asked why I hadn't performed an ECG yet, well doc, I would have had to literally climb over the top of your six foot shoulders or shove you out of the way to do it! Ugh.

[mybrowneyedgirl, BSN, RN]

Ugh! I work Level II and I have the same issues. When I am the primary nurse, I often kick extra nurses and techs out and if there's time I will let the nurses in the trauma know which person will be running for meds, who's starting lines and sending labs so I can try to avoid the chaos, but it's still not a well run machine.

[MassED, BSN, RN]

I agree, browneyedgirl, some machines run well, some don't. It's difficult to pinpoint, but I just find that there are those that just work well together and can anticipate what the other is doing so each person has their own job and no one is double backing. I do think there's a big part of control for ER nurses and those that can't let things go and control everything tend to lose it.

[shoegalRN, RN]

I work in a Level I Trauma teaching hospital. Our traumas run like this:

You have two nurses assigned for trauma during the entire shift. One nurse is the circulator, the other nurse is the scribe. You also have techs assigned to get the pt on the monitor, cut off clothes, help transport, run labs and get blood.

Depending on the severity of the trauma, trauma surgeons may be called in or not. We classify our traumas into two cateogories, Class A or Class B. Class A would be considered stab wound/GSW to chest, abdomen, head, a trauma code, or a MVA rollover with a passenger dead on scene. A Class B would be a GSW to thigh, lower extremities, a fall greater than 20 feet, pedrestrian vs car. Trauma surgeons are only paged to Class A traumas, however a Class B can be upgraded to a Class A and we will paged them accordingly.

While in a trauma, I pay attention to my resident running it. If I am scribing the event, I ask my residents questions, such as which drugs he/she want drawn up, what interventions they would like, etc. If Trauma surgery comes down and states "we need to take this pt to the OR now!", I will make sure our trauma labs have been drawn for cross and match, cross and screen and if not, I will make it known to the surgeon those labs have not been drawn as of yet. If they havent been drawn and the trauma surgeon says we are moving NOW, I make sure the cirulator goes up to the OR with the pt and draw the labs in the OR.

We do have ER attendings in our traumas, but they mostly stand back and guide the residents. For the most part, our Trauma surgeons and ER docs work well together.

[HikingNinja, BSN, MSN, DNP, RN, APRN, NP]

I'm in a Level II trauma center. We have three trauma levels. Class 1 - ex GSW to the chest, Class 2 - stab wound to flank but VS stable, GCS 15 etc. Class 3 - ex MVC restrained passenger, >12 inch intrusion into cabin, LOC, highway speed, no obvious injuries life threatening injuries and VS stable, GCS 15.

For Class I - the ED doc might be there in the beginning until the trauma doc can get there ( 2-4 min?), but then the trauma team consists of three trauma RNs each with an assigned role (they get assigned at the beginning of the shift), anesthesia doc is there, EKG, lab, CT, rad tech are all there on standby.

Class II - the only difference is no anesthesia doc as intubation may not be necessary.

Class III - the ER doc sees, not a full activation, but still taken care of by trauma RNs in a separate trauma area - two beds per bay.

During a full level 1 or 2 activation there are 3 trauma RNs. One acts as the recorder this person is also in charge of the drugs, orders, making sure the assessment called out by the trauma doc is recorded, etc. They are in control of the bay. The recorder has the power to kick out gawkers and/or extraneous staff. The other two trauma RNs have specific sides of the patient they are to stay and certain tasks associated with those sides of the bed. For example the RN on the patient's left side is responsible for set up and assist of things like an open thoracotomy, while the RN on the patient's right is pumping blood into them with a rapid infuser.

Oh, and OR shows up for level 1 & 2 activations also. We use predone up narc and med packs also so you always use the same things and don't have to go running around for stuff usually.

And our trauma docs are the gods of the trauma bay. No one gives any orders but them in upper level activations, if and ED doc or resident tries without the trauma docs blessing they are promptly kicked out of the bay.

All in all the traumas run fairly smoothly.

[meandragonbrett]

Our trauma ER is a totally separate depart,ent from the medicine ER. There are no ER docs that attend our traumas. Only the attending trauma surgeon on call, the surgery resident on trauma, and the Trauma CRNA. Trauma RNs don't work ER and ER doesn't come to trauma.