Alasdair Macmillan reflects on the importance of establishing priorities within a surgical team when deployed to a war zone
Staff in a simulated hospital where realtime scenarios can be rehearsed and repeated as required
In modern NHS practice it can be easy to forget that we share a common aim. When a trauma team comes together in a war, a disparate group of people has to work together, with a shared focus, co-operating to treat seriously injured soldiers and civilians quickly, efficiently and effectively.
Tuckman summed up teamwork in 1965: "Forming, Storming, Norming, Performing". First, the team is brought together during the Forming phase. The hospital exercise is the Storm, with simulated casualties pouring in. The exercise is also the Norming, as each member of the team finds his place and issues and problems are discussed. It’s also an opportunity for rehearsing scenarios and actions together, physically and mentally. Performing, of course, is the team doing its job for real.
"All members of the team, from the soldier on the ground to the surgical team in the operating theatre, have a common understanding and purpose"
For a team to work, it must have vision, a mission and values. These are all ingrained into daily military practice. All members of the team, from the soldier on the ground to the surgical team in the operating theatre, have a common understanding and purpose.
Before deployment, the team is prepared by exercising at least twice together in a simulated environment. Interpersonal and group dynamics are worked out, with opportunities to rehearse and repeat scenarios in a realistic time frame. Importantly, they will also have the opportunity to interact socially, both inside and outside of the exercise.
As the exercise takes place in ‘real time’, there can be periods of great urgency, for example a mass casualty simulation. This scenario, which almost all hospitals in the UK would struggle to cope with, stretches the team, and can become very realistic for the players. The group will learn to work as the clinical situation dictates. This allows for rest, relaxation, discussion of what has occurred, what could be done better, what may happen next, and how this can be dealt with. Not only is the physical aspect of the exercise attended to, the social and psychological sides are being explored by each individual, and by the facilitators running the exercise.
Scenario play moulds what will be the operational surgical team – including surgeons, the emergency medicine specialist, anaesthetist and operating department practitioners and, importantly, the theatre nurse manager. An individual often overlooked, but hugely relevant in the team, is the Padre. His importance as a calming influence and supportive figure cannot be overestimated.
The Medical Director’s appreciation of the ‘bigger picture’ of the hospital overall and the battlefield situation is vital in making decisions about patient care. The surgical team needs to respond to the overall scenario by adjusting decisions and sometimes changing completely what needs to be done at a particular stage.
The next time the team comes together is in the theatre of operations. Sometimes it is literally in the deployed operating theatre. As each individual has NHS clinical currency, exercise experience, and the operational imprint already formed, it is relatively easy to come up to speed with the ongoing situation. A very brief and focused handover from your predecessor may be all you get, so flexibility is key, as circumstances are evolving and changing all the time. Even over the course of a single day, the nature of injuries can change or the operational environment switch completely. For example, from rapid evacuation to prolonged hold of casualties, if air assets are compromised by something as simple as weather conditions.
On operations, the team gets together before casualties arrive to discuss various approaches to treatment. Often the initial report is inaccurate or evolving, but this exercises the team before arrival. The theatre nurse manager is critical to co-ordinating what needs to happen in theatre and what equipment and assets are required. Beyond this, limited ‘performance’ discussion is needed as much of the care pathway has been standardised as ‘drills’, known by every soldier in the field through to the specialists who will ultimately be performing damage control treatment.
The huge energy of improvised explosive devices requires a strategy:
• Control of haemorrhage
• The surgical team will take "time out" to decide priorities
• Theatre will be organized which may involve the use of multiple operating tables or multiple teams on a single patient
• Resuscitation will be both physiological and surgical
• Aortic cross-clamping and then more distal arterial control as appropriate
• Pelvic packing carried out in a particular fashion for high energy pelvic injuries
• Fixation of the pelvis
• Debridement
The emphasis at this stage is on Damage Control Surgery, which is not necessarily definitive. It may be primarily resuscitative. The surgical control of catastrophic bleeding may require clamping/control of major arteries, and packing of body cavities. Damage to hollow viscera will not involve anastomoses at this time, but quick and simple control of soiling. The General Surgeon will do this with the help of the Orthopaedic colleague. When bony fixation and debridement is required, the Orthopaedic surgeon takes the lead and the General Surgeon will assist.
Time may then be required for "anaesthetic catch-up" to reverse the inevitable hypothermia, acidosis and coagulopathy associated with major trauma. The casualty is warmed. Fluid resuscitation is based on replacing blood with blood and not crystalloid. Transfusion principles are a 1:1 ratio of fresh frozen plasma to packed red cells with one combined unit of platelets for every four. Thrombo-elastography allows real-time assessment of the blood’s ability to sustain clotting and allows the intensivist, who may well be present in the operating theatre, to judge whether platelets, fresh frozen plasma and or cryoprecipitate is required. This is time well spent as it is not unusual for arterial pH to rise from 6.7 to normal and a Base Excess of -27 to revert towards normal within the hour.
This is a period for the operating team to take stock and decide on the next phase of treatment. The patient may transfer to ITU for further resuscitation and care or may head for CT to assess other injuries. It may be felt that further surgery is still required to complete any debridement. It is often found at this time that the body has warmed, the blood is coagulating and tissues which were friable and oozing before, now handle better.
While this process is completed, the planning for evacuation of the casualty to the UK has already begun. The seamless transfer of the patient to the Critical Care Air Support Team and then on to Role 4 hospitalisation in the UK can often take place in less than 24 hours. Continuing intensive and surgical care is provided in transit and the beginnings of rehabilitation care take place at this time.
Once the patient returns to the UK, the deployed team, consisting of surgical specialties, intensivists and pain specialists, will discuss cases by conference call with ongoing progress and results from the UK specialists involved. This completes the cycle of audit, allowing reflection on the immediate care of the casualty and the opportunity to adapt future treatments.
Alasdair Macmillan
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