The Trauma team is a multidisciplinary group of individuals drawn from the specialties of emergency medicine, intensive care, surgery, nursing, allied health and support staff, who work together as a team to assess and manage the trauma patient.  Their actions are coordinated by a team leader.

The primary aims of the team are to rapidly resuscitate and stabilise the patient, prioritise and determine the nature and extent of the injuries and prepare the patient for transport to the site of definitive care

Clearly allocated roles and responsibilities are crucial for successful team performance.

The systematic allocation of roles should follow the recommended defaults below, unless the clinical needs of the injured patients are clearly better met by an alternative allocation of staff, based on the resources available at any given time.   In the allocation of roles, as in the allocation of tasks and treatment, the over-riding principle is to ensure that optimal care is delivered to the patient at all times.  Each team member has a number of key tasks they are responsible for, both in the pre-arrival and the reception and resuscitation phases of patient care.

Trauma team leader (TTL) 

Default allocation

• ED consultant
• Other suitable allocations: ED fellow

The trauma team leader is required to have experience and medical expertise in the management of injured patients.  They must also possess excellent non-technical skills in order to effectively optimise team performance.  

Key points:

• Performs pre-arrival team briefing and utilises trauma checklist prior to every trauma presentation
• Allocates roles and tasks according to skill and experience
• Establishes consistent communication with team members
• Provides a shared mental model for the trauma team

Pre-arrival:

• Assesses pre-hospital notification and activate Trauma Team if criteria are met
• Synthesises pre-hospital information to anticipate potential injuries, procedures and priorities prior to arrival of patient
• Utilises trauma checklist 
• Allocates roles to available personnel, ensuring each individual is appropriately skilled to undertake the expected responsibilities of their role for this patient.
• Ensures personal protective equipment (PPE), including a lead apron, is worn by all key personnel prior to patient arrival
• Identifies estimated weight prior to arrival to enable preparation of drugs.
• Ensures ED radiographer on standby.
• Determines expected requirement for CT imaging and facilitate communication with medical imaging staff.
• Contacts pathology for blood in motion if anticipated / MTP activation

Post-arrival:

• Receives handover and ensure room is quiet
• Ensures social work available to support family
• Organises patient disposition with relevant specialty teams including paediatric surgery, orthopaedics, neurosurgery and PICU
• If team members are delayed, on arrival identifies them and their specialty
• Ensures the safe, timely  and thorough assessment and management of the major trauma patient, and that all team members are aware of the priorities for patient care
  
• Performs a formal handover to an appropriate medical team member, at the appropriate time and place, in the best interests for the patient.
• Ensures the role of trauma team leader is formally handed over.
• Documents primary and secondary survey, synthesis and ongoing plan; this responsibility may be delegated to another suitable team member.

At all times, ensures good team communication through use of clear and concise statements, along with closed loop communication. Asks for help / clarification if required.

Team leader support (TLS)

Default allocation

• PICU doctor
• Other suitable allocations: Paediatric Surgery registrar, relevant specialty surgeon

The allocation of a team member to Team Leader Support should ideally take into account the patient’s expected destination after ED (e.g. PICU for a patient expected to be admitted to PICU) and/or maximising speciality-specific decision-making (e.g. Neurosurgery for significant neurotrauma).

Key points:

• A second senior clinician who is tasked with maintaining situational awareness, but not tasked with significant decision making - thereby facilitating an ability to actively engage in identifying actual or potential errors
• Provides cognitive support to the Trauma team leader, by helping reduce their cognitive load

Pre-arrival and throughout entire reception/resuscitation phase:

• Provides collegiate and cognitive support to the Trauma Team Leader (TTL), thereby reducing the likelihood of team errors in care, especially errors of omission.
• Independently and actively engages in identifying potential and actual errors  
• Ensures team communication remains through the TTL, with emphasis on closing the loop and shared understanding in communication between team members
• Assists with contacting the relevant specialty units via phone
• Liaises with medical imaging and blood bank at request of the team leader. 
  

Post arrival:

• Reviews results of investigations as directed by TTL, communicating findings through the TTL
• Talks to the family, gains further history and keeps them up to date. In conjunction with the TTL determines, if and when, it is appropriate for them to be in the resuscitation room.
• Ensures that blood bank is aware of patient transfer outside of ED, or assigns responsibility to the team member allocated to the transfusion role.
• Supports TTL when formal handover of patient takes place. If part of receiving team (e.g. PICU / Paediatric Surgery) then handover may be given to the Team Leader Support

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts team leader to new information as it becomes available. Asks for help / clarification if required.

Airway doctor 

Default allocation

• Anaesthetist
• Other suitable allocations: PICU doctor, ED doctor

It is acknowledged that airway management skills are shared between all three craft groups and the TTL is responsible for allocating the team member most able to meet this patient’s airway needs.

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
  
• Utilises pre-intubation checklist to prepare equipment and drugs
• Ensures airway template completed with appropriate equipment
• Discusses airway plan with airway nurse
• Clearly states airway plan A,B,C and D to whole team
• Ensures all communication is through the TTL

Post arrival:

• Controls log roll to allow Patslide® insertion to transfer patient to resuscitation trolley
• Applies oxygen, if not already present
• Performs airway and anterior neck assessment
• Assesses GCS and pupils
• Communicates airway assessment to Team Leader
• Manages airway obstruction: suction, basic manoeuvers, OPA/NPA
• Assesses need for intervention/intubation and communicates this with TTL
• Performs intubation if appropriate
• Ensures cervical spine immobilisation at all times
• Monitors central nervous system status

Post intubation:

• Ensures intubated patient has orogastric tube placed
• Confirms ventilator settings with airway nurse
• Establishes patient on ventilator
• Ensures appropriate ongoing sedation has been commenced
• Accompanies and cares for the intubated patient on transfer within the hospital
• Takes equipment and drugs to CT including emergency airway equipment / fluids / analgesia / paralytics
• Gives regular updates to TTL regarding airway management and respiratory status of patient

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts team leader to new information as it becomes available. Asks for help / clarification if required.

Assessment doctor

Default allocation

• ED doctor
• Other suitable allocations: PICU doctor, surgeon

Allocation of the surgeon to the assessment doctor role may confound the utility of the surgeon in procedural support of patient care.

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
• Liaises with Team Leader with regards to anticipated injuries
• Pre-orders investigations via trauma panel (radiology and blood tests - FBE, U&E, LFT, Lipase, Coags, Group & Hold/Cross-match, VBG) and medication where possible
• Ensures all communication is through the TTL

Post arrival:

• Assists with transfer of patient to ED trolley
• Breathing: clearly state vital signs. Identify thoracic life threats
• Circulation: clearly state vital signs. Identify presence and cause of shock if present, extended FAST scan (if appropriate)
• Disability: Assess neurological status before paralysing anaesthetic agents used
• Ensure patient is kept warm
• Check BSL
• Clearly states findings to TTL/ Nurse Team Leader /Scribe
• Requests relevant X-rays as part of the primary survey
• AMPLE history, reassure patient on arrival, explain what is happening
• Performs Secondary survey
• Conveys results of investigations to TTL
• Following on from primary and secondary survey, review results of investigations in light of clinical findings with TTL

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Procedure doctor

Default allocation

• Surgeon
• Other suitable allocations: PICU doctor, ED doctor

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
• Prepares IV access equipment, including two large bore IV’s, rapid infuser equipment, IO equipment
• Locates and prepares ultrasound machine if required (FAST scanning of the abdomen is rarely required in pre-pubertal children, but ultrasound may help with venous access, identifying pneumothoraces, haemothoraces, and pericardial effusion +/- tamponade)
• Prepares other equipment as guided by TTL based on anticipated injuries. May include pelvic binder, equipment for chest decompression
• Ensures all communication is through the TTL

Post arrival:

• Assists with transfer of patient to ED trolley
• Obtains IV access: 2 x large bore lines & obtain blood for pathology
• Ensures bloods have been sent.  Checks results.
• Performs chest decompression / intercostal catheter insertion
• Aids airway doctor in difficult airway management
• Applies pelvic binder with assessment doctor
• Liaises with blood bank for blood requirements. Allocates doctor to continue communication with blood bank if rapid transfusion is required.

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Nurse team leader

Default allocation

• Senior Emergency Department (ED) nurse (competent in airway, scribe & circulation)

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
• Ensures any specific equipment that is required is turned on
  
• Ensures Trauma Call Out is activated where criteria are met
• Assists in allocation Nursing Team roles
• Supports deficits in roles

Post arrival:

• Facilitates logistical aspects of patient care
• Is available for advice and support for nurses
• Has overall view of patient and liaise important observations with TTL
• Organises additional staff/PSA/Blood bank/Equipment/Social Worker
• Bed Management – liaises with OT/CT/PICU
• Optimises co-ordination of Family Care 
• Liaises with blood bank regarding potential transfusions if known requirement

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Scribe

Default allocation

• ED nurse

Pre-arrival:

• Ensures team have PPE clothing / lead aprons on
• Identifies role to team
  
• Documents trauma team members, their time of arrival, & allocated roles

Post arrival:

• Responsible for recording:
  • Time of Patient Arrival
  • I – MIST - handover from ambulance personnel (see Handover section in Human factors in trauma reception and resuscitation)
  • Names of staff in attendance and their roles
  • Examination findings of Primary and Secondary Assessment
  • Regular Vital Signs and Glasgow Coma Scale/AVPU
  • Fluids/Drugs/Intravenous Fluids and Blood Administration – Ensure medications and fluids are appropriately prescribed
  • Time of MTP activation (where activated)
  • A summary of injuries
  • Patients response to treatment
  • Documents interventions and procedures
  • Transfer time and location of patient
• Actively prompting for examination findings where necessary
• Ensuring medications and fluids are appropriately prescribed
• To communicate trends in vital signs where identified
• Can activate MTP if required
• Can order induction drugs and fluid bolus if required
• Can order fluid bolus if required

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Airway Nurse

Default allocation

• PICU nurse
• Other suitable allocations: ED nurse

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
  
• Clarifies airway plan with Airway Doctor and TTL
• Completes emergency pre intubation checklist with Airway Doctor & TTL
• Set up for Intubation as per Airway Equipment Template
• Ensures Glidescope is in resuscitation room and working
• Clarifies Intubation Drugs with Airway Doctor and TTL
• Set up Ventilator and Ventilation setting as instructed by Airway Doctor and TTL
• Ensures appropriate thoracic elevation device in place (children <8yrs)

Post arrival:

• Assists with Log Roll transfer to resuscitation trolley
• Ensures cervical spine immobilisation during transfer
• Ensures cervical spine collar is applied if applicable
• Assists with Intubation and Airway Management
• Manages ventilator
• Inserts oro-gastric tube if required and informs scribe of gastric aspirate
• Accompanies the intubated patient during transfer with appropriate airway equipment for transfer

At all times, ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Circulation nurses

1. Procedure Nurse
2. Transfusion Nurse
3. Infusion Nurse

It is widely recognised that the nursing roles during a trauma are extremely busy.  Many of the tasks involved are related to optimising the patients circulation either through the employment of haemostatic procedures, or transfusion of blood, or infusion of medication.  As such, at RCH, there has been the adoption of the umbrella term of "circulation nurse" which incorporates three sub-roles of procedure, transfusion and infusion nurse.  Not all severely injured children will require the presence of all three circulation nurses (most children do not need a transfusion of blood for example), and whether one, two or all three of the sub-roles are utilised at any given trauma will be discussed on a patient to patient basis and are dependent on patient need and staff availability.  There may be a significant overlap and fluidity between the tasks and responsibility of these three nursing roles where there are not three members of the nursing staff filling these roles.

Procedure Nurse

Default allocation

• ED nurse
• Other suitable allocations: PICU nurse

Pre-arrival

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
  
• Ensures special procedures trolley is in resus bay
• Prepares IV fluids / IV access equipment / IO kit 
• Sets up for procedures as instructed by TTL
• Prepares Pelvic Binder when instructed by TTL

Post arrival

• Assists with Log Roll of patient
• Assists in applying Pelvic Binder if required
• Assists with specific procedures chest drain, IDC, splinting
• Applies pressure pads to significant haemorrhage and wound dressing as instructed
• Sets up for Arterial and Central access lines

At all times, ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Transfusion Nurse

Default allocation

• ED nurse
• Other suitable allocations: PICU nurse

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
  
• Primary role of managing blood product transfusions
• Must be familiar with MTP
• Prime Level 1 Belmont Rapid infuser if requested

Post arrival:

• Assists with Log Roll of patient
• Manages the Belmont Rapid infuser and administers blood if MTP is activated
• Ensure safe practice and appropriate checking of transfusions is adhered to
• Liaise with blood bank regarding transfusions, ensuring medical team involvement
• Liaise with Team Leader regarding transfusions
• Liaise with Scribe to ensure strict documentation and FBC updated as transfusions progress

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Infusion Nurse

 Default allocation

• ED nurse
• Other suitable allocations: PICU nurse

Pre-arrival:

• Ensures PPE is worn, including gown, gloves, lead apron and goggles
  
• Prepare drugs as requested: RSI drugs & analgesia (liaises with Airway nurse)
• Prepares infusions and boluses for sedation as instructed by TTL
• Prepares trauma shears, patient property bag, warm blanket and Bear Hugger if required
• Ensures transport equipment is ready (transport bag, drug box, transport monitor)

Post arrival:

• Starts Clock Timer
• Assists with Log roll transfer of patient
• Removes Clothing and covers with warm Blanket or Bear Hugger
• Attaches monitoring and obtains first vital signs as a priority
• Assists with IV access, collecting and labelling bloods
• Confirms and prepares correct medications and doses
• Effectively communicates all medications and fluids administered to the TTL
• Preforms chest compressions during cardiac arrest
• Prepares for transfer of patient

At all times ensures good team communication through use of clear and concise statements, along with closed loop communication, and alert TTL to new information as it becomes available. Asks for help / clarification if required.

RADIOGRAPHER

Pre-arrival:

• Preloads plates for imaging

Post arrival:

• Performs trauma series X-Rays during primary survey (CXR, lateral C-Spine, +/-Pelvis) as requested
• Performs additional imaging after secondary survey as required
• Remains with trauma team until told he/ she is no longer required
• Ensures appropriate requests are made prior to leaving department
• Liaise with CT radiographer to provide timely availability of CT if required

At all times, ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Social worker

• Greets family when they arrive and escorts them to designated area, or supports them during the resuscitation
• Talks to the family regarding events surrounding the trauma
• Supports family members and attempts to ascertain their perceptions about the trauma
• Informs medical and nursing staff that the family is present in the waiting room and, if possible, introduces these groups
• Obtains a psycho-social history
• Provides the family with general information regarding their child's care
• Counsels and supports family through initial crisis
• Informs medical and nursing staff of significant aspects of psychosocial history obtained from the family
• Provide family with information package, including books for siblings
• Help arrange home transportation for the family
• Notify staff when family leaves
• On the following day, phone the family to determine if any other immediate needs have arisen that can be met by the hospital
• Ensure that appropriate ongoing follow-up is provided as necessary, such as referral to bereavement counselling or parent support group
• If a trauma patient dies in the resuscitation area, or is brought in DOA, the social work staff member will:
• Be present when the family are informed of the death
• Work with the immediate grief of the family
• Assist parents in contacting needed family, friends, clergy
• Help family decide if they wish to see the body and support them through this
• Assist family with immediate plans for funeral, autopsy, organ donation, etc.
• Support family during process of notification to the coroner, identifying body to police etc.

At all times, ensures good team communication through use of clear and concise statements, along with closed loop communication, and alerts TTL to new information as it becomes available. Asks for help / clarification if required.

Trauma Service staff 

The staff members of the RCH Trauma Service in their trauma role are not directly involved in the clinical care of patients.  However, the Director of Trauma as well as the Trauma Fellow have clinical appointments within the hospital and therefore may become involved in the care of a trauma patient in their role as a Paediatric Surgical Consultant or Emergency Doctor (taking on one of the above roles).    

When the trauma team is activated, the trauma service team (director, fellow and manager) are notified also.  The trauma service team will in-hours attend the trauma call and will help with tasks as per request of the TTL.

The trauma service team can facilitate adherence to procedures and guidelines during a paediatric trauma.