The team leader isn’t always the senior registrar (or the Director of ICU)

About four years ago I took some leave from my position and worked in another department for 6 months or so. I didn’t do this because I wanted to, I did it because I had to. That will be a much later post, and is a much different story from this one. I mention it here because the story from this post happened in the midst of the worst week of my career that forced me away for 6 months and nearly out of nursing…

 

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The team leader isn’t always the senior registrar (or the Director of the ICU)…

At the start of our night shift we had an admission. She was a pillion passenger on a motorbike and had gone from the motorbike into a window, which had been thoughtfully opened by the rider of the bike who had been jettisoned though the glass head first, milliseconds earlier. He had died at the scene.

She had a head injury and severe liver damage and multiple long bone fractures and that night would require two operations in theatre and two trips to CT, as well as activated factor VII and the Massive Tranfusion Protocol. We couldn’t bring her ICP below 50mmHg, and she quite frankly had us all concerned.

All that was to come.

Right now she had just arrived in our ICU and had been too unstable for the emergency department to do a head scan, so our job was to stabilise her and get her to radiology on another floor and then back to our floor to OT.

A large team of nurses and junior doctors gathered at the bedside, ready to do what was required. The Director of ICU was the consultant and was standing back, arms casually folded, making decisions and guiding the team. Sometime over the next half hour the night shift doctors started drifting in, taking over from their day shift counterparts so they could prepare for the medical handover round.

Eventually, the consultant decided that if she was going to get to radiology now was the time. I was the ACCESS (or Bay nurse, or float nurse) in the area. He nodded towards me and I started delegating nurses to collect equipment, medications, transfer monitors and test transport ventilators, which is the kind of thing an ICU consultant might not know about. Keeping an eye on our activity and the patient the consultant started filling in the details for the night shift senior registrar.

I work with a truly wonderful team. Most of the senior nurses are interchangeable within roles, although we all have unique approaches to problems and situations. Right now, senior nurses and spare staff were completing delegated tasks, reporting to me and awaiting the next objective. I had people undertaking several steps of the process at the same time. Admittedly, this was before tabards clearly stating “Team Leader” or “Airway Nurse”…

Having been nominated to transfer the patient to CT, the oncoming senior registrar quickly looked around and asked the team at the bedspace if he could have some medications, (he seemed to ask everyone, or no-one, but not any one person) and proceded to list propofol (running already), noradrenaline (also running), vecuronium (infusing due to ICP), morphine (check) and midazolam (you guessed it, also being given) and then added mertaminol (something new).

Not only did he request those medications, he yelled those requests, with strengths and concentrations, and he yelled them over the quiet that had characterised our efforts so far.

Naturally, no-one much paid him attention. Certainly no one dropped what they were doing and ran to the medication room.

In the relative quiet after the senior registrar had stopped yelling, the Director of ICU quietly turned to the senior registrar and said “I don’t think you’re in charge just at the minute, do you?” And pointed in my direction.

A look of understanding crossed the registrar’s face, (the force was strong with this one) and he asked me for his preferred medications. I quickly ran him through what he currently had, and asked two nurses to ensure adequate supplies had been made up for the trip.

The patient was out the door and on the way in less than 10 minutes from the time the decision to go had been communicated.

At the recent smaccGOLD 2014 conference on the Gold Coast, several presenters addressed issues surrounding “tribes”: nursing, medical, ICU, Emergency, Anaesthetics, Pre-Hospital and specialities. (Big shout out to @Socratic_EM, @cliffreid et al.) All presenters promoted a blurring of the “tribes” for the betterment of patient care.

Similarly, recent practice changes and coronial investigations have promoted readily identifiable clothing, tabards of stickers identifying roles in resuscitation or intervention situations, especially when teams are ad hoc and staff capabilities are unclear.

All of these ideas and practice changes are valuable. But that isn’t what this post is about.

When we do know our staff, and we do know our own capabilities, we shouldn’t be afraid to cede responsibility to another with more knowledge of a process or procedure. We don’t lose power or respect, rather we empower others and ourselves.

The Director of ICU wasn’t any less in charge of the situation, and wasn’t any less of a decision maker. He knew what his role was and so did everyone else there. But it had been a long time since he had actually prepped a patient for a trip to radiology.

Even without identifying markers, everyone else knew their roles as well. And amongst the senior staff, any one of us could have coordinated the transfer. It was just via allocation that it was me.

Similarly, if the senior registrar had taken a moment to assess the situation, breathe in, and look – he wouldn’t have been at a disadvantage when it came his turn to lead the team to and from the radiology department, either. We learn these lessons in first aid, in PHTLS, ALS, ATLS and all the other courses we do. Sometimes it is a matter of safety, and sometimes just to ease the wheels of communication and teamwork.

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