In Situ ED, General Surgery & ITU Simulation - Trauma Major Haemorrhage

Learning Objectives

Learning objectives - Non clinical

• Team leadership and team-working
• Multi-Specialty collaboration
• Communication
• How to make the trauma team work together effectively

Learning objectives - Clinical (Medical)

• Recognising and managing major haemorrhage in a trauma context.
• Management options for splenic injury

Learning objectives - Clinical (Nursing)

• Using the Belmont rapid infuser for massive transfusion
• Emergency blood collection procedure

Faculty - Alex Belcher, Ben Short, Ben Atkinson, Paul Sykes

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RCEM Curriculum Coverage Topics (SLOs)

SLO 2 - Support the ED team by answering clinical questions and making safe decisions
SLO 3 - Identify sick adult patients, be able to resuscitate and stabilise and know when it is appropriate to stop
SLO 4 - Care for acutely injured patients across the full range of complexity
SLO 7 - Deal with complex and challenging situations in the work place

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FICM Curriculum Coverage Topics (HiLLOs)

HiLLO 5 - Doctors specialising in Intensive Care Medicine can identify, resuscitate and stabilise a critically ill patient, as well as undertake their safe intra-hospital or inter-hospital transfer to an appropriately staffed and equipped facility.
HiLLO 7 - Specialists in Intensive Care Medicine can provide pre-operative resuscitation and optimisation of patients, deliver post-operative clinical care including optimising their physiological status, provide advanced organ system support and manage their pain relief.

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The Case

• Trauma patient (simulated patient) who is brought into navigation
• Moved to resus by navigation team.
• Initial assessment shows unwell patient with possible chest/abdominal injury and wrist injury.
• Patient very upset and in pain with the wrist.
• Given painkillers in resus
• Tachycardia worsened, becomes hypotensive and has a syncopal episode.
• Simulated patient swapped to manikin
• POCUS performed which showed free fluid LUQ
• Massive transfusion activated.
• Blood products via Belmont with TXA.
• Patient stabilised enough to go to theatre (IR also considered)
• Transfer to theatres

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Take Home Points

• Belmont is relatively easy to use once trained and it is very important to keep self skilled / competent in its use
• Shared mental model and clear communication between teams

Latent Threats identified

• Access to surgical team when in theatre (initially unable to get hold of senior surgical decision maker)
• Unable to locate cordless phones in resus (both being used) - more old school corded phones required

Some comments from participant feedback from own reflections:

• Major haemorrhage protocol and its location on the intranet
• Importance of clear communication and allocation of roles
• Don’t panic
• What do to in that situation
• Organise nursing
• Vocalise what I’m doing. Name/role stickers.
• Refresher for the Belmont - allocating 2 people helps
• Summarise to get team on same page
• Importance of the whiteboard for disseminating information / scribing
• Timely trauma call is vital

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Suggested improvements from participants:

• More simulations please
• Use of the whiteboard more during resuscitations
• More phones in resus
• Reduced number of observers
• Utilise all nurses
• More practice / sessions like this
• Do concurrent cases with another trauma case coming in about 10-20 minutes after the first
• Keep blood in the ED

Faculty Debrief:

• Crowd control
• Explore way of watching in another room remotely (leaving only 1 or 2 facilitators in resus)

Future sessions:

• Session in November - paediatric focus