How do traumas run in your ED?

[R5RN, BSN, RN, EMT-P]

My ED is a level III trauma center and there's no real flow to how things go when we get trauma patients. Recently when I was in a trauma, both the trauma surgeon with a surgical PA and the ED physician were all trying to do assessments at the same time. I was the "circulating" nurse and another nurse was scribe. Our charge nurse came in and told me to start doing an assessment (I had been doing some other intervention at the time but I don't remember exactly what I had been doing) while the physicians and PA were actively doing assessments. I found no reason for four separate people to be assessing the same things on a patient at the same time. But the physicians are not in the habit of reporting their findings out loud, so the scribe is unable to obtain information they need for documentation until later or when someone repeats the assessment for the purpose of documentation. This is just a small example of what I perceive to be a little off.

I'd like to hear an overview of how things go when you get a trauma patient. Such as who is in the room and who does what? How are your assignments set up? As in, where do the staff members come from and what staff members are involved? Are there sort of set roles prior to going into a trauma (e.g. 1 nurse is responsible for interventions and meds, an ED tech is present, a nurse or someone else scribes, what is the charge nurse's responsibility)? Who takes over the rest of the nurse's assignment if that is pertinent to how your traumas are done?

Any other info you can provide would be awesome.

[ADM_RustyShackleford, MSN, RN]

I work at a Level 1 Trauma Center and am TNCC certified - so I might be able to provide some insight. It sounds like what is going on in your traumas is very disconnected and redundant. Traumas should be done in a systematic manner, with every team member performing clearly defined duties/roles.

TNCC bases their assessment using the mnemonic ABCDEFG(lmnop)HI:

Airway

Breathing

Circulation

Disability

Exposure

Full set of vitals

Get adjuncts (Labs, Monitors, NG(OG) tubes, Oxygen, Pain)

History

Inspect posterior surfaces

Each member of the team is responsible for a certain part of the total assessment of the patient. Effective communication helps ensure that tasks can be done simultaneously and not redundantly. The team members should include: Trauma Team Surgeons, ED Attending/Resident, 2 RNs, Respiratory, EDTech/Paramedic -- There's also a good amount of ancillary staff (Xray, Chaplain, Security, etc) who are in the room as well.

At my hospital - we have a team of trauma surgeons, which includes an attending, Sr resident, and Jr resident (intern) -- they are responsible for the care of the patient. The attending oversees the Sr, who is in charge of assessing the patient, the mechanism of injury, obtaining history, determining/dictating orders to the primary RN. If any surgical interventions are needed - they are the ones doing it. The Trauma Jr is responsible for helping remove clothes, palpating pulses, noting any injuries, and if they are lucky, the FAST exam (however, the Sr usually does this). The ED attending physician and resident are at the head of the bed and are in control of Airway, that's it. However, they assist with assessment of breath sounds, pupils, TMs, any head injuries as a courtesy due to their placement in relation of the patient. The Primary RN is in charge of the patient's care and everything it involves - recording events, entering orders, and facilitating any needs (CT, OR, blood, etc). They also are crowd control - if they can't hear assessments being stated aloud, they can't record it - so having a quiet room with only essential information being said out loud is key. The Secondary RN is in charge of obtaining IV access and labs, along with any other nursing interventions -- Meds, NG, foley. The ED tech removes clothes and attaches telemetry monitoring. Respiratory applies SpO2/ETCO2 monitoring and obtains ABGs - along with assisting intubation/ventilations.

Not sure how it is done at other hospitals, but we have an RN (or two) assigned to Trauma, so they shouldn't really have much of an assignment other than trauma patients. If there are none, the trauma nurse floats and aids other RNs in the ED.

There is kind of a lot going on at once, but I hope I painted a good picture for you. If you have any other questions, let me know!