Team-Based EMS
By Alan Perry
November 4, 2015
Introduction
What do you want to call it? “High Performance EMS”, “Pit Crew EMS”, “Code Team”, “insert cute name here”, it really doesn’t matter, these terms all convey the same meaning; an organized and efficient approach to patient care. Regardless of the name, it won’t just happen without some effort on the part of the system and the providers. I would like to explore some ways of dissecting it from a team and teamwork perspective. I am going to discuss the ideas and practice in this article in three phases; Understanding the idea and how to visualize it, Defining the priorities of scene and team management, and Illustrating application of the idea when applied to any given crew configuration. I want to present it this way so the material can be presented and absorbed in a way that builds from concept to technical skill, with the final product being integrated into a flexible and effective system.
Concept
Why a team approach
is needed
Cardiac arrest treatment has
become much more technical and precise; the data behind modern resuscitation
tools and skills is solid and still building. Sudden Cardiac Arrest is one of
the most studied pre-hospital medical emergencies. Building a solid team
approach will allow your organization to maximize the use of your team, and the
resources available to them, to improve patient outcomes.
The Coach and Players
All teams need a coach and
players that are familiar with the game and the responsibilities and
capabilities of their team mates. An EMS/Fire crew is no different. Coaches are
strategist, know the strengths and weaknesses of their team, the disease
process and the tools and tactics required to succeed. Players know their area of responsibility and
what performance goals must be met. Both are committed to the team’s success
and a good outcome for the patient.
Planning to win
When working a code we should
have a specific goal in mind, in the past we would be happy with simply
regaining a pulse, we resigned ourselves to the likelihood that most would not
survive, that is changing. It is becoming increasingly likely with our new
tools and tactics, that victims will survive, not only survive, but remain
neurologically intact and live normal lives. In some places survival rates from
witnessed cardiac arrest are near 50%, clearly they play to win. Planning to
win means that you are willing to commit your team to training with the tools
and tactics that are proven to work, it will require going beyond simply
knowing what to do, you must bring all the elements together multiple
times and in multiple scenarios to build your teams confidence and competence.
You will know you are there when the team can function calmly, flawlessly and
smoothly in even the most difficult circumstance.
Building your
play-book
To reach the level of play
required for an elite EMS team, we will have to improve the way we train,
deploy, act and recover. Training is not just something we do to deploy a new
device, tactic or skill, it is something we must do constantly so the team can
build routines, muscle memory and fine-tuned personal interactions. Deployment
of new tools, tactics and skills must be preceded by training, reinforced and
evaluated, to determine if the material has been delivered and retained. When we
respond and act, we must practice that team-based approach that brings all of
the technology and skill we possess into play to produce the best possible
outcome for the patient. When we recover from these calls we must extol both
the good and bad when we debrief, learning from both and discovering new ways
to improve.
Technicalities
Understanding the
Priorities during Cardiac Arrest
#1 Safety:
From dispatch through recovery, you cannot help if you don’t
get there or you or your crew is injured.
#2 CPR:
By-stander CPR followed seamlessly by high quality
uninterrupted CPR by EMS is proven to be the most beneficial action for
patients in sudden cardiac arrest.
#3 Airway
Controlling the airway includes opening and sealing the
airway with an ITD to improve circulation in cardiac arrest with CPR
#4 Defibrillation:
Cardiac arrest from ventricular fibrillation can be resolved
quickly with counter shocks delivered as early as possible.
#5 Ventilation
Not a priority during the first 2 minutes, but necessary
beyond that, delivered with BVM and capnography to guide patient care.
#6 IV Access & pharmacology
Also not an initial priority,
establishes a route for IV fluids and pharmacological agents if indicated.
#7 Rule outs (H’s & T’s)
Finding and treating the cause of
the arrest is at least as important as reversing the arrest to prevent
re-arrest.
#8 Post care
The jobs not over after the
patient regains a pulse; perform a 12-lead, employ pharmacology and electrical
therapy to manage this very unstable patient, employ therapeutic hypothermia if
permitted and indicated.
Team Roster
Safety- Individual (and entire
team); senior officer, maintains scene security and safety, serves as patient
and family advocate.
Coach- Team leader; senior paramedic or EMS
supervisor – directs code after determining nature of call and indications for
resuscitation.
Compression team- At least
two persons to alternate compressing the chest wall, initially may be an
individual until additional resources arrive, will alternate with airway team
every 2 minutes.
Airway team- At least two persons to manage airway
and ventilations, initially can be an individual who secures airway seal with
ITD until additional resources arrive, will alternate with Compression team
every 2 minutes.
Defibrillator- Specialist; exposes patient and
applies defib pads, charges defibrillator, applies electrical therapy on
command from lead once patient is cleared, connect capnography lead, applies
additional electrodes and non-invasive monitoring tools when possible and acquires
12-lead if indicated.
IV access- Specialist; set up and
establishes IO access, administers fluids and drugs PRN on direction of team
lead. Assist with obtaining glucometry.
Pharmacology- Specialist (ALS); assists team lead,
obtains, draws, constitutes indicated medications, mixes drips, assist IV
position with administration.
Integration
A model for initial
team assignments
Position assignments are a tool
that can assist your team in accomplishing complex tasks. In a work environment
that frequently includes overtime and swing assignments with apparatus and
crews we may not be familiar with. Standardized position assignments can help
personnel and the organization achieve a higher level of performance in spite
of staffing issues, and more complex treatment goals. One goal is to minimize
the shift/station/apparatus variability that occurs as a normal process when
crews find what works for them. This is fine if you know you will always be
working with the same people on the same piece of equipment, but that seems to
be the exception now rather than the norm. Another goal is developing a system
for deploying and delivering more advanced tools and skills consistently and
effectively. Consider that the practice of team-based EMS is already promoting
teamwork and assigned roles in dealing with critical medical events like
cardiac arrest. Because of the advantages, it seems reasonable that we could
start practicing that way on every call to improve our performance and patient
outcomes. We already apply these pre-assigned roles for firefighting
activities, it should not be much of a stretch to apply it to EMS as well.
Below is an outline model of how it might look, again it does not replace good
decision making and must remain adaptable.
Alpha (Officer)
• Scene safety/Command/Communications
with EDC
• Patient/Family advocate
• Assist with collecting patient
information and history
• Assist with staging equipment and
manpower
• Assume #2 CPR position during
resuscitation if needed
Bravo (Jumpseat)
•
Lead EMS provider- first to patient – marks
patient contact
• Deploys with Tablet and monitor
• Assesses patient and determines need
for resuscitation
• Primary patient assessment/interview/determine
nature of call
• Directs care of patient by crew
• Documents interventions with accurate
time stamps
• Develops and communicates treatment
plan to team
• ALS performs procedures outside others
scope of practice
• Communicates with patient’s family and
med control PRN
Charlie (Jump seat)
• Forcible entry if needed
• Deploys with blue & red bags
• Assumes #1 compressor position during
resuscitation
• Obtains patient vitals & physical
exam
• Procedures as directed by lead within
scope of practice
Delta (Driver)
• Deploys with drug & IV boxes
• Assumes control of airway during
resuscitation
• Secure scene for incoming resources
• Stage patient moving equipment
• Procedures as directed by lead within
scope of practice
ALS (any
position)
• If an ALS provider is
assigned to a position other that Bravo/lead EMS provider, they will assume the
role of the Bravo/lead EMS provider if the patient is presumed, or found to be
in need of, ALS care and/or evaluation.
Summary
Emergency medical services are
increasingly driven by outcomes and the application of tools and skills with
proven benefits. Delivery of these devices and skills requires greater
organization and communication to produce favorable outcomes. The adoption of
formal crew assignments and a team-based approach to EMS can produce more
efficient and effective care and thereby improved outcomes. It is a new way of
thinking for most but not one we are unfamiliar with. Our daily activities, finances, team sports,
card games and hunting all require strategy and tactics to produce a successful
outcome. We can apply teamwork, new tactics and technology to deliver our
services to save more lives and improve quality of life for survivors.
Ready? Set? Practice!!
