Effective communication is essential in successfully assessing and resuscitating critically ill trauma patients, especially in times of high stress. It is important to maintain a common vocabulary, creating a shared mental model of the case to avoid assumptions.
Creating a shared model of the patient’s situation allows personnel from differing backgrounds to understand both the clinical and logistical implications of the case. It ensures that team members are familiar with one another’s roles and responsibilities; that they are able to anticipate the needs of other team members, and have a high level of adaptive capacity9. This collaborative approach helps break down boundaries between individuals with varying levels of experience. It also helps reduce the perception of a power differential between outside specialists coming into the emergency department. Stating common treatment goals prevents individual team members veering off on counterproductive tangents. An example of this is an orthopaedic surgeon fixating on a dislocated ankle while the patient has a life-threatening pneumothorax that needs dealing with first. A way of doing this is to brief the team prior to the patient’s arrival.
Tacit knowledge can be described as that which is acquired through practice and experience and may be difficult to communicate10. The same idea can be applied when referring to communication skills in the ED. Tacit communication is communication that occurs, often without words, in which the intention is never actually stated. One example of this is an experienced anaesthetist putting their hand out and expecting to be handed the laryngoscope by their assistant without actually asking for it because that is the way they do things. It should be obvious that this method can lead to problems, especially in occasional teams in times of high stress.
By making communication explicit and specific such as ‘When I do … I would like you to do …’ and allowing questions to be asked, errors and critical incidences can be avoided. In times of high stress communication often shifts from an explicit to a tacit form without the team being aware of it. This leads to missed information and poor outcomes.
One technique that can help avoid this is using closed-loop communication.
The formation of a trauma or deteriorating patient response team may be very different among health services with highly variable capacity. Developments in both technological hardware and communication infrastructure have allowed healthcare services to extend their information base beyond in-house capacity, through using videoconference (VC) technologies. Difficult major trauma patient presentations, particularly when there is no or only off-site medical cover, require additional support to optimise patient care. The connection to a ‘remote expert’ to assist in identifying differential diagnoses and to guide ongoing assessment and intervention can be facilitated by Adult Retrieval Victoria (ARV) consultants. Where structures do not exist to allow VC consultation, voice-only teleconferencing with ARV allows for ongoing dialogue regarding best management of the major trauma patient.
Current structures allow for many Victorian health services to connect with critical care coordinators at ARV to provide expert guidance in managing major trauma patients. Engaging a VC support person has been shown to improve the confidence and abilities of attendant staff in managing acutely unwell patients. Systems currently in place allow for high-quality video and voice transmission to add value to the on-site clinical assessment of major trauma patients. The capacity of VC support lends itself to wide-ranging consultation, including reviewing x-rays and electrocardiographs in addition to major trauma patient assessment and interventional support.
Interactions over VC and teleconference technologies may require a change in approach, with some additional training and exposure, and the dissolution of barriers to involving an additional and external expert. However, identified positive outcomes necessitate health services embracing the use of VC and teleconference technologies to build staff confidence and skills and therefore improved patient outcomes.