Trauma is easy — trauma teams are hard


Christopher Hicks iChris Hickss a Canadian Emergency Physician and trauma team leader (TLL) at an urban inner city teaching hospital and Level 1 trauma centre in Toronto, Ontario. He is also a clinician educator with the department of medicine, conducting simulation-based research on optimizing team performance during critical events and resuscitation, and Associate program director with the EM residency training program at the University of Toronto.

Chris is coming to SWEETs16 to teach at the in situ simulation workshop together with Jesse Spurr. During SWEETs he is giving two presentations, one is about the role of the emergency physician in trauma care from a Canadian perspective. (Thursday 8.50-9.10)


Q: What is the role of the emergency physician in trauma care in Canada and how do you see it evolving?


Chris: This very much depends on geography.  In some hospitals, the trauma team IS the emergency team, led by an EM physician.  In some centres, there is a designated trauma team that responds to major trauma activations, a process informed by pre-hospital field trauma guidelines.  Most hospitals with a trauma team also have a designated trauma team leader (TTL), typically a staff physician or fellow with specialized trauma expertise.  At my hospital, the TTL role doesn’t belong to any particular specialty — about half of our TTLs are EM physicians, with the remainder from general surgery, orthopedics, and neurosurgery.  In addition, there is always one trauma surgeon on call, although their participation in most trauma team activations is not routine (they may be asked to attend depending on the nature or severity of the trauma).


There has been an evolution over the past 10-15 years in recognizing that the role of the TTL is more a particular set of skills rather than belonging to a specific training discipline.  Having said that, at our institution in particular the interaction between EM and other specialties involved in trauma care (and trauma surgery in particular) is generally very collegial and accepting.


Q: Has it been a struggle to get there?


Not in particular — I did additional trauma team work as part of my training, but I would argue that most EM physicians possess the necessary procedural and resuscitative skills to perform the TTL role.  Additional knowledge of organ-specific injuries and trauma systems is required, and this was probably the steepest learning curve for me when first stepping into the role, back in 2009.


Q: Canada is, just like Sweden, a safe country with relatively little trauma. How do you train your emergency physicians for the job?


We have a fair bit of major trauma — at St. Michael’s we average about 2 trauma team activations per day; at our other regional trauma centre the numbers are about double that.  Augmenting that, we have a robust simulation program that focuses by in large on team-based skills.  As I am fond of saying, trauma is easy — trauma teams are hard.


Q: Your other talk is about trauma care in the elderly (Wednesday 15:30-15:50). What is your take home message there?


  1. Mechanism of injury is less important than you think when predicting severity of injury — unless it’s in the elderly patient (where mechanism seems to matter a lot)


  1. Having said that, for elderly patients (loosely defined as age > 65), always assume the worst, and work backwards, even if the mechanism seems trivial


  1. The physiology will fool you — BP and HR in particular are poor predictors of the presence or absence of shock or severe hemorrhage; if concerned, seek other more physiologicindicatorsof tissue perfusion (lactate, base deficit, blood gas)


  1. Damned blood thinners — they’re all on ’em! Bear that in mind when dealing with a bleeding, elderly patient