Apparently 12-1 is not an acceptable ratio when it comes to his & hers blogging… So in the interest of continued marital harmony, here’s a few thoughts to newbies on making yourself heard in the resus room.
It happens to the best of us. You’ve been sitting around the station all night and finally decide it’s safe to slip the boots off, only to be immediately reminded that the trauma gods do in fact enjoy tormenting you. On come the lights, quickly followed by a dispatcher’s pressured voice. As you glance at the clock reading 3am, a few words stand out. Gunshot wound. Bleeding. Unconscious.
For the next fifteen minutes you’re on autopilot – reflexively cutting away clothing, occluding that bubbling hole in the chest and dropping a needle down through the second intercostal space, just like you were trained. You watch the vital signs move back towards normal and you justifiably feel like a total badass. Time to load and go.
As you wheel into the trauma bay at your local Level 1, you’re confident you’ve done everything right. There’s the team, gowned and gloved, ready to take over.
Inside your brain is screaming, “Work mouth, you bastard!” Now is the time to prove to all these doctors how awesome you are, how you saved this guy’s life. “I’ve done all the hard work. Speak damn you!”
“Ummm.. This is Steve, he’s a male..”
“Steve! He’s a male! And.. we found him outside the bar – the one over off Main, well Main and 3rd… closer to 4th. He has asthma and…”
“Airway’s patent! Breath sounds clear bilaterally!” It’s too late. You lost them.
Want to keep the brief attention of your ED colleagues and trauma team? Here’s how:
1. Figure out who’s doing the talking – most critical patients roll in flanked by a entourage of medics, EMTs, fire fighters and/or police. Add to that the near-limitless helping hands in a large ED and there’s usually no need for the AIC to be occupied with distracting tasks like moving the patient off the stretcher or switching O2 from the portable tank to wall supply. Instead, the AIC should be at the foot of bed, addressing the entire room. Yes, everyone – the doctors, nurses, techs, social worker, chaplain and ogling med students ALL need to hear what’s going with this guy, so be ready to project your voice and speak clearly. And if you are the trainee, don’t disappear to clean the stretcher – stick around and listen. It’ll be your turn before you know it.
2. Take a deep breath – You made it. Even if the patient is actively coding, you’re here and your job is almost done. The blood splattered sidewalk, flashing lights, noise and confusion are all behind you. It’s our job to shut up and listen, and we will – for about 30 seconds. Starting your turnover in a calm and collected manner is the first sign to us those precious seconds will be well spent.
3. Age. Sex. Chief complaint/most pressing issue. – The first two always go off without a hitch. The third seems obvious, but every now and then it just takes an inexplicably long time to get around to mentioning the multiple stab wounds or EKG reading ***STEMI***STEMI***STEMI***. By the end of your first sentence we should know who your patient is and what went so wrong with their day to now be spending it with all these highly trained individuals.
4. Stay focused – This is not the time for an exhaustive presentation of the history and physical. A remote history of paronychia isn’t of much interest in someone with hemiparesis, but the time of onset certainly is. We can wait to hear she takes 500mg of Vitamin C daily, but Coumadin is a med I want to know about up front. By far this is the most difficult thing to master, because it often means reading our minds, knowing what’s important and what isn’t. A few stand out items in no particular order would be: loss of consciousness yes or no, symptoms improving or worsening, mechanism of injury, relevant surgeries, and medications including blood thinners, cardiac drugs such as beta blockers, and insulin.
5. Vitals – What are they now? Were they different at any time? What do you mean you only got one set?
6. Injuries, EKGs, physical exam and what did you do about it? – This is your chance to brag. “Patient was altered and EKG showed sinus bradycardia. I gave 0.5mg Atropine x1 with improvement in heart rate and mental status.” “The right leg was shortened with deformity at the mid-thigh. I gave 100mcg of Fentanyl and applied a traction splint.”
7. Access – ET tube, King airway, NPA? What size IVs and where are they? Did you drill IOs instead? Kudos if you did.
That’s it really. In 15-30 seconds we should hear what’s wrong with this person, how did it happen, what changes happened while he/she was with you and what did you do about it.
Giving a concise, accurate turnover takes practice. The pressure is on and your adrenaline is already up. You’re mentally exhausted, but those last few moments before he or she is off your stretcher are often the only insight doctors get into what’s going on, so make them count. Once the dust has settled, feel free to pull any of us aside for some feedback.
4 thoughts on “Be Heard in the Bay: Tips for Turnover on Critical Patients”
Great posting! Even though I am an EMT and not likely to be giving turnover in these types of cases, your suggested order of presentation and importance seems right for every call turnover. I like your writing style – succinct, with a little humor.
I like to start off by taking a few deep breaths while walking from the ambulance to the ER room. This helps calm me down as I tend to be a bit amped with adrenaline with high acuity patients. I’m not saying it works all the time, but I try.
That’s a great idea. I do the same thing for intubations. Deep breath and visualize the tube successfully going in.
Someone on Facebook did bring up a good point in response to this post – that if you present as a transfer from an outside hospital (OSH) the team is less likely to listen to you, presumably because they had a call from the OSH regarding the patient and need for transfer. While that’s usually true, I’ve certainly received transfers where the Attending who took the call has since gone home, and the record is on a piece of paper I never knew to read. Either way, the staff at the receiving facility should listen to you, because thing certainly could have changed en route.